Phone *

(###)

###

####

Date Purchased

MM

DD

YYYY

Date Vacated

MM

DD

YYYY

Any losses in the last 5 years? *

Yes

No

Are all buildings totally vacant?

YES

NO

Are all buildings 4 units or less?

YES

NO

In the past 5 years, has applicant been convicted or indicted for arson, fraud, bribery or any other arson related crime?

YES

NO

Has applicant had a foreclosure, repossession or bankruptcy in the past 5 years?

YES

NO

Is any building constructed on stilts?

YES

NO

Is any building intended for demolition?

YES

NO

Is any building partially constructed?

YES

NO

Is any building listed on a historical register?

YES

NO

Is any building constructed of logs?

YES

NO

Is the risk a condominium unit?

YES

NO

Are all buildings locked/secured to prevent unauthorized entry?

YES

NO

Will the building(s) be undergoing renovations of any kind during the policy term?

YES

NO

Is there a pool, pond, lake or hot tub on any of the premises?

YES

NO

Is any lot size more than 5 acres?

YES

NO

Are there any nuisance hazards on any of the properties (swing sets, vehicles, debris, trampoline, fuel tanks, underground tanks, etc.)?

YES

NO

Does someone check on the property on a regular basis?

YES

NO

Is it equiped with Functioning Cicuit Breakers?

YES

NO

Active Fire Sprinkler system?

YES

NO

Active Central Station Alarm System?

YES

NO