| For Help Call (573)358-3100 |
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| Fields marked (*) are mandatory. |
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| Broker/Company | |
| Submitted By | |
| Phone Number | |
| Fax Number | |
| E-Mail Address | |
| Name Insured | |
| Location Address | |
| Required for each location |
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| 1. Years of experience of insured | |
| Years this location owned by insured | |
| 2. Any periodic check of Stairs, Balconies, Walkways, etc? | |
| How often? | |
| 3. Occupancy (%) | |
| If Less than 90%, explain | |
| A. Any government subsidized housing? | |
| If yes, what percent? | |
| B. Any student renters? | |
| If yes, what percent? | |
| C. Is building a retirement/elderly care facility? | |
| 1) Any health care services provided? | |
| 2) Cafeteria on site? | |
| D. Management on site? | |
| E. Employees perform maintenance at site? | |
| F. Do you allow tenants to have dogs? | |
| Maximum size dog allowed? | |
| 4. Construction |
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| A. Is location within 2500 feet of 'brush area?' | |
| B. Building construction | |
| C. Roof type | |
| D. Type of Wiring | |
| If Aluminum, Updated? | |
| 1) If aluminum, are all receptacles and switches fixed using the CopAlum Crimp Method? | |
| E. Number of Stories | |
| If over three (3) stories |
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| 1) Are interior stairways enclosed and equiped with self-closing fire doors on each floor? | |
| 2) Pull type 'Life Safety' alarm? | |
| 3) Alarm on each floor? | |
| 4) Is there a live safety sprinkler system covering stairs and hallways? | |
| F. Smoke Alarm in each living unit? | |
| If yes | |
| 1) Bedroom | |
| 2) Kitchen | |
| 3) Hallway leading to bedroom | |
| 4) Common interior hallways and stairways | |
| G. Emergency lighting in interior corridors longer than 75 ft? | |
| H. Lighted EXIT signs in interior corridors? | |
| I. Any carports? | |
| # of spaces? | |
| J. If multiple buildings, what is the separation between buildings | |
| 5. Annual Rental Income |
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| 1 bedroom | |
| # of units | |
| 2 bedroom | |
| # of units | |
| Other | |
| # of units | |
| 6. Swimming Pool(s)? | |
| Spa(s)/Jacuzzi? | |
| A. If yes, is it fenced? | |
| How tall is fence? | |
| B. Does it have a self-closing/self-latching gate? | |
| C. Diving board(s)? | |
| How high above water? | |
| D. Pool rules clearly posted in the pool area? | |
| E. Lifesaving equipment (i.e., life ring, shephards hook) in pool area? | |
| 7. Playground(s)? | |
| If yes, how is is secured? | |
| A. Type of surface (i.e., asphalt, grass, sand)? | |
| B. Equipment installed (i.e., swings, slides, jungle gym, etc.)? | |
| 8. Tennis/basketball courts? | |
| If yes, how many? | |
| 9. Golf courses? | |
| If yes, is it for the exclusive use of the members? | |
| 10. Other Recreational Facilities? | |
| Provide full details | |
| 11. Entire Property Fenced? | |
| Automatic Access Gate? | |
| 12. Security Provided? | |
| If yes | |
| A. Employees of the insured? | |
| B. Subcontracted? | |
| C. Are you named as Additional Insured? | |
| D. Days of week? | |
| E. 24-Hours on duty? | |
| 13. Are tenants screened prior to leasing? | |
| A. Credit check? | |
| B. Criminal checks? | |
| 14. Are employees screened? | |
| A. References? | |
| B. Prior jobs | |
| C. Credit checks? | |
| D. Criminal checks? | |
| 15. Crime and vandalism in neighborhood? | |
| 16. Are tenants informed of crime and vandalism activity? | |
| 17. Is there any regular news bulletins by assured? | |
| 18. HOA only — Does the Association own or operate |
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| A. Electric utility? | |
| B. Gas utility? | |
| C. Sewer utility? | |
| D. Water utility? | |
| E. Garbage or refuse collection? | |
| F. Landfill of garbage dump? | |