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Submitted By
Phone Number
Fax Number
E-Mail Address
Name Insured
Location Address
Required for each location
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
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
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
1 bedroom
# of units
2 bedroom
# of units
# of units
6. Swimming Pool(s)?
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
A. Electric utility?
B. Gas utility?
C. Sewer utility?
D. Water utility?
E. Garbage or refuse collection?
F. Landfill of garbage dump?