|
| Insured name |
|
| Address |
|
| City |
|
| State* |
|
| Zip |
|
| Policy number |
|
| Policy inception date |
|
| Policy expiration date |
|
| Effective date of change |
|
|
| Change request type |
|
| Location number |
|
| Building number |
|
| Address |
|
| City |
|
| State* |
|
| Zip |
|
| City limits |
|
| Interest |
|
| Year built |
|
| Part occupied |
|
|
| Premises number |
|
| Building number |
|
| Change request type |
|
|
| Subject of insurance |
|
| Amount ($) |
|
| Percent coinsurance |
|
| Valuation |
|
| Causes of loss |
|
| Percent inflation guard |
|
| Deductible |
|
| Forms and conditions to apply |
|
|
| Subject of insurance |
|
| Amount ($) |
|
| Percent coinsurance |
|
| Valuation |
|
| Causes of loss |
|
| Percent inflation guard |
|
| Deductible |
|
| Forms and conditions to apply |
|
| Additional coverages, options, restrictions, endorsements, and rating information |
|
| Construction type |
|
| Distance to fire hydrant (feet) |
|
| Distance to fire station (miles) |
|
| Fire district/Code number |
|
| Prot CL |
|
| Number of stories |
|
| Number of basements |
|
| Year built |
|
| Total area |
|
| Building improvements: wiring |
|
| If yes, year of improvement |
|
| Building improvements: roofing |
|
| If yes, year of improvement |
|
| Building improvements: plumbing |
|
| If yes, year of improvement |
|
| Building improvements: heating |
|
| If yes, year of improvement |
|
| Building improvements: other |
|
| If yes, year of improvement and explain other |
|
| Building code grade |
|
| Inspected |
|
| Roof type |
|
| Tax code |
|
| Other occupancies |
|
| Right exposure and distance |
|
| Left exposure and distance |
|
| Rear exposure and distance |
|
| Burglar alarm type |
|
| Certificate number |
|
| Expiration date |
|
| Extent |
|
| Grade |
|
| Central station |
|
| With keys |
|
| Clock hourly |
|
| Central station |
|
| Local gong |
|
| Burglar alarm installed and serviced by |
|
| Number of guards/watchmen |
|
| Premises fire protection (sprinklers, standpipes, CO2 chemical systems) |
|
| Fire alarm manufacturer |
|
|
| Percent coinsurance |
|
| Change request type |
|
|
| Number |
|
| Model year |
|
| Description (type, manufacturer, model, capacity, etc.) |
|
| Date purchased |
|
| New/Used |
|
| Amount of insurance |
|
|
| Number |
|
| Model year |
|
| Description (type, manufacturer, model, capacity, etc.) |
|
| Date purchased |
|
| New/Used |
|
| Amount of insurance |
|
|
| Limit of liability ($) |
|
| Retained limit ($) |
|
| Other, describe |
|
|
| Change request type |
|
| Type of interest |
|
| Name of additional interest |
|
| Address |
|
| City |
|
| State* |
|
| Zip |
|
| Reference number |
|
| Item description |
|
| Is certificate required |
|
| Interest in premises number |
|
| Interest in building number |
|
| Interest in vehicle number |
|
| Interest in boat number |
|
| Interest in scheduled item number |
|
| Interest in other number |
|
