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Policy #

*Insured

*Address

City State Zip Code

*Phone Ext. Fax

Change requested by

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Property Description - location to be Added Deleted

Property Location

Address

City State Zip Code

County Year built

Occupancy (How property is used.)

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scroll down and click on the SUBMIT button.

ADDITIONAL INTEREST - Mortgagee/Additional Insured/Loss Payee:

Name

Address

City State Zip Code

Loan/Account # Phone

BUILDING INFORMATION

Number of stories:
Total Square Footage: square feet

Basement:		sq ft.
1st Floor:		sq ft.
2nd Floor:		sq ft.
3rd Floor:		sq ft.

Other (please explain):

Construction Type:
Frame Masonry Non–Combustible
Joisted Masonry Other

Inside City Limits Yes No

Name of Fire Department:

Miles to Fire Dept: Feet to Hydrant:

Type of heating system: Air Conditioning: Yes No

Electrical System Fuse Circuit Breakers

Date of last Electrical System Inspection:
Date of last wiring update:
Date of last plumbing update:
Date of last roof maintenance:

Boiler on Premises Yes No

PROTECTION
Servicing of Extinguishers Yes No - Servicing Date:
Sprinkler System Full Partial None
Automatic Extinguishing Systems over cooking surfaces Yes No

ALARMS
Smoke Detector on each floor Yes No
Heat Detectors Central Local None
Pull Alarms Central Local None
Burglar Alarms Central Local None
Central-Detectors Smoke Heat Other:
Name of Alarm Company:
Phone # of Alarm Company:
Building Locked when not in use Yes No
Building on Historical Register Yes No

Comments/Additional Information:

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