Vacant Partially Vacant Bldgrenoinspectionreportformat2!8!08

8/14/2019 Vacant Partially Vacant Bldgrenoinspectionreportformat2!8!08

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UNITED STATES LIABILITY INSURANCE GROUPA BERKSHIRE HATHAWAY COMPANY

Named Insured: Policy Number:

Form of Business: Corporation Partnership Individual Other:

Interviewed/Title:

Surveyed by: Survey Date:

Mailing Address:Location Information

Loc

#Street Address City State

Zip

Code

Square

Feet

Year

BuiltConstruction

Protection

Class

# of

Storie

General Information

1. Is the building completely vacant? (If no complete the General and Partially Vacant section of this form) Yes No

2. What is the intended disposition? Sell Find Lessee Occupy Demolish Other:

3. Any losses in past three years? If yes give complete description: Yes No

Date Type/Description: Paid Reserved Open/Closed$ $

__________ ____________________________________ $_________ $_________ __________________________ ____________________________________ $_________ $_________ ________________

R* A

4. Does the insured own the building (or is insured a tenant with contractual requirement to insure the building)? No Yes

5. Is the building located on a farm? Yes No

6. Is the building located on 250 or more acres? Yes No

7. Is the building currently damaged fire, wind or otherwise? Yes No

8. Is the building locked, boarded up, or secured (if partially vacant, applies to vacant portion) No Yes

9. Any signs of unauthorized entry into the building? Yes No

10. Are any renovations, development plans or other construction activities being performed during our policy term? Yes No(if yes, complete the Building Under Renovation section of this form)

11. Any tenant evicted within the past 60 days? Yes No

12. Is the insured actively engaged in trying to sell/lease the building? No Yes

13. Is the building obsolete with no further potential? Yes No

14. How long has the building been vacant?

15. Any financial difficulties learned as a result of the vacancy?

16. How often are checks made on the premises? By whom?

Partially Vacant N/A

17. Describe tenants:

18. Does the building have aluminum or knob & tube wiring? Yes No

19. Is all electric on functional circuit breakers? No Yes

20. Are there functioning and operational smoke/heat detectors in those units, common areas and mechanical areas,which you physically have inspected? No Yes

Vacant & Partially Vacant Building and Building Under Renovation Inspection Report Form 2-08-08 edition Page 1 of 3

Vacant, Partially Vacant, and Building Under Renovations Building Inspection Report


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21. Is there a valid certificate of occupancy for each tenant? No Yes

Property Information

22. Are there any adjacent exposures? (If yes answer 22a.) Yes No

22a. Are any of the adjacent exposures vacant and NOT locked, boarded up, or secured from unauthorized entry? No Yes

23. Is the building in an area prone to floods, tornados or brush fires? Yes No

24. Is there a sprinkler system? (If yes answer 24a thru 24c) Yes No

24a.Are functioning and operational sprinklers covering 100% of building? Yes No

24b. Is heat maintained at a level throughout the building to prevent pipes from freezing? No Yes

24c. If heat is not maintained, is system drained and shut off? No Yes

25. Any accumulation of debris? Yes No

26. Is this a mobile home? Yes No

Property Special Cause of Loss27. Is plumbing completely PVC or Copper? No Yes

28. Is all electric connected to functional circuit breakers? No Yes

29. Roof construction:

30. Roof age (if flat, indicate date last recoated):

Building Under Renovation N/A

31. Cost of Renovation or Rehab:

32. Who is performing the renovations? Applicant Contractor Other:

33. How many years of experience does the applicant/contractor have in conducting renovation projects?

34. Are any structural renovations planned? Yes No

35. Do the renovations include any additions to the building? Yes No

36. Do the premises contain any underground storage tanks? Yes No

37. Does the project involve any of the following: bridges; dams; tunnels; bubble buildings; green houses; wastewater treatment facilities; airport hangers; silos; chemical, energy co-generation or petroleum facilities; radio,television or communication towers? Yes No

38. Are any demolition or blasting operations planned? Yes No

* Provide details on any responses in the R column: None

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Specific Underwriting Questions:

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__Recommendations/Comments: No Yes (if yes list below)

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Vacant Partially Vacant Bldgrenoinspectionreportformat2!8!08