Location Address(s)
Construction:
Fire Resistive
Masonry Non-Comb.
Joisted Masonry
Frame
Other
If other, please describe:
Building value (if owned):
Contents Value:
Business Income value:
Loss of Income value:
Square feet of building area:
Wiring, Year
Roofing, Year
Plumbing, Year
Heating, Year
How many claims did you have in the last 5 years:
0
1 2 3 4 5 6 7 8 9
Year of claims:
None
2012
2011
2010
2009
2008
Number of claims:
Amount paid:
$
Year of claims:
None
2012
2011
2010
2009
2008
Number of claims:
Amount paid:
$
Year of claims:
None
2012
2011
2010
2009
2008
Number of claims:
Amount paid:
$
Year of claims:
None
2012
2011
2010
2009
2008
Number of claims:
Amount paid:
$
Year of claims:
None
2012
2011
2010
2009
2008
Number of claims:
Amount paid:
$
Year of claims:
None
2012
2011
2010
2009
2008
Number of claims:
Amount paid:
$
Year of claims:
None
2012
2011
2010
2009
2008
Number of claims:
Amount paid:
$
Year of claims:
None
2012
2011
2010
2009
2008
Number of claims:
Amount paid:
$
Year of claims:
None
2012
2011
2010
2009
2008
Number of claims:
Amount paid:
$
Prior Insurance Carrier:
Policy Expiration:
Expiring premium:
Deductible:
Please list all scheduled equipment, ED&P and Improvements & Betterments that you want covered by this
property policy. Please select the number you would like to list:
0
1 2 3 4 5 6 7 8 9
Location:
Item:
Quantity:
Manufacturer:
Cost New:
Insured Value:
Location:
Item:
Quantity:
Manufacturer:
Cost New:
Insured Value:
Location:
Item:
Quantity:
Manufacturer:
Cost New:
Insured Value:
Location:
Item:
Quantity:
Manufacturer:
Cost New:
Insured Value:
Location:
Item:
Quantity:
Manufacturer:
Cost New:
Insured Value:
Location:
Item:
Quantity:
Manufacturer:
Cost New:
Insured Value:
Location:
Item:
Quantity:
Manufacturer:
Cost New:
Insured Value:
Location:
Item:
Quantity:
Manufacturer:
Cost New:
Insured Value:
Location:
Item:
Quantity:
Manufacturer:
Cost New:
Insured Value:
Facility Sprinklered?
Yes
No
Fire Alarm:
Yes
No
Fire Alarm:
Cen Station
Local Gong
Burglar Alarm:
Yes
No
Type:
Burglar Alarm:
Cen Station
Local Gong
Surveillance cameras?
Yes
No
Surveillance cameras?
Inside
Outside
Owner or Tenant:
Owner
Tenant
Do you have an emergency evacuation plan?
Yes
No
Distance to Nearest Fire Station:
Distance to nearest fire hydrant:
Number of Stories:
How often are hydrants & hoses checked?
Do all indoor facilities comply with all local life-safety codes?
Yes
No
Do you comply with all local, state, building, concession, sanitary codes?
Yes
No
How many exits from premises?
Is there an emergency lighting system on premises and/or building?
Yes
No
How many full time employees?
How many part time/seasonal employees?