Inspection Form
William E. Casey Insurer Services, Inc.
Company Name:
*
Jencap
Jencap/Quaker
Johnson and Johnson
DeCotis Insurance
Market Finders
Safety Insurance
Other
Inspector's Name:
*
Please Select
Ashley Freudenthal
Augusto Recabo
Daniel Caragia
David Benson
David Morin
Dick Herman
Erick Hartz
Frank Thibeault
George Yazbeck
Gina Silvia
Greg McEachern
James Hanley
Jim McEachern
Johnny Walker
Keith McEachern
Kristian Mahaffey
Latania Knights
Mark Kramer
Mark Melville
Mark Rasmussen
Moses Germain
Pamela Bunker
Nicole Messier
Robert Brown
Robert Grota
Sandy King
William Bierce
William Casey
Assigned Inspector:
INSPECTORS CAN"T SEE THIS- FOR AUTOMATION
Insured's Name:
*
Type exactly how it appears on request
Agency:
*
Policy #:
*
Street Address
City
State
Zip Code
Inspection Date:
*
-
Month
-
Day
Year
Date
Contact Name
*
Contact Information (Phone Number(s) & Email)
*
Include Lock Box info
Description of Risk:
*
Be as detailed as possible. Overall description of risk. List occupancy (# of units, what occupies each unit, (owner, tenant, vacant), commercial or residential.
Does the Insured Own the Building?
*
Yes
No (Insured is a tenant)
Yes, under separate entity
Condo Association
Vacant Land (No building)
Unknown
Other
Estimated Purchase Date:
When did the insured purchase the property?
Prior Losses
*
Yes
No
Unknown
Other
Prior Loss Description:
List what the prior loss was and if it's been addressed. Take pictures.
Type of Inspection:
*
Full (interior / Exterior access)
Exterior Only
Full (Vacant Land)
Does the risk contain utilities
Yes
No (select No if you do not have access)
Describe Occupancy (check all that apply):
*
The risk is owner occupied
The risk is tenant occupied
The risk is vacant
The risk is a business (Insured is a tenant of the building)
Insured operates a Daycare
Insured operates a Restaurant
The risk is vacant and under renovation
New Construction
The risk is a condo association
The risk is a secondary residence
The risk is a seasonal residence
The risk is vacant land
Exterior Only Inspection- Homeowners
Other
Does the inspection require a replacement cost?
Yes
No
Homeowners: Is the risk a single family dwelling, located within 10 miles of the coastline?
Yes
No
Yes - (Click for Exterior Only Inspection)
Does the risk contain a commercial kitchen?
Yes
No
Jencap/Quaker Only (Rental Income)
Owner occupied- No rental income
The risk is vacant- No rental income
Requested by inspector
$ Enter Rental Amount $
Exterior:
Square Footage:
Year Built:
Number of Stories:
Foundation
Concrete
Concrete Block
Fieldstone
Brick
Crawl Space
Pylons
Slab
Other
Exterior Siding:
Wood Clapboard
Cement Fiber Clapboard
Vinyl
Vinyl Shake Shingles
Wood Shake Shingles
T-111 Wood Siding
Aluminum
Steel Sheathing/Metal
Asbestos Shingles
Asphalt Shingles
Stucco
Concrete Block
Brick
Stone/Brick Veneer
EIFS
Other
Roof Type:
Gable
Hip
Flat
Mansard
Gambrel
Sloped
Shed
Other
Roof Covering:
Asphalt Shingles (3-tab)
Asphalt Shingles (architectural)
Rubber Membrane
Tar & Gravel
Wood Shake
Slate
Metal
Clay Tile
Solar Panels
Unknown/Not visible
Other
Roof Age:
New
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
Over 25 years
Original
Unknown/Not visible
Other
Roof Condition:
Excellent
Good
Fair
Poor
N/A
Other
Off-Street Parking:
Yes
No
Other
Garage:
No
Attached One Car
Attached Two Car
Attached Three Car
Detached One Car
Detached Two Car
Detached Three Car
One Car Under
Two Car Under
Other
Outbuildings:
Small Shed
Medium Shed
Large Shed
Barn
Large Two Story Barn
Pool House
Workshop
Guesthouse/ADU
Chicken Coop
None
Other
Surrounding Area:
*
Residential
Commercial
Industrial
Urban
Suburban
Rural
Swimming Pool:
*
Yes
No
Swimming Pool Type:
In-ground
Above-ground
In-door
Diving Board
Water Slide
Other
Swimming Pool Security:
Secured
Not Secured
Fenced with locked gate
Rules/Signage Posted
Lifeguard
Covered
Other
Hot Tub:
Yes
No
Exposures
What is located to the left, right, and rear of the building/unit you are inspecting.
Left Exposure:
*
Abuts
Attached
Within 5 feet
Within 15 feet
Within 25 feet
Within 50 feet
Within 100 feet
Within 200 feet
Within 500 feet
Other
Description:
*
Vacant Land
Commercial Building
Residential Building
Mixed-Use Building
Multi-Family/Apartment Building
Commercial Unit
Wooded Area
Wetlands
Lake/Pond
Ocean
Park/Playground
Other
Right Exposure:
*
Abuts
Attached
Within 5 feet
Within 15 feet
Within 25 feet
Within 50 feet
Within 100 feet
Within 200 feet
Within 500 feet
Other
Description:
*
Vacant Land
Commercial Building
Residential Building
Mixed-Use Building
Multi-Family/Apartment Building
Commercial Unit
Wooded Area
Wetlands
Lake/Pond
Ocean
Park/Playground
Other
Rear Exposure:
*
Abuts
Attached
Within 5 feet
Within 15 feet
Within 25 feet
Within 50 feet
Within 100 feet
Within 200 feet
Within 500 feet
Other
Description:
*
Vacant Land
Commercial Building
Residential Building
Mixed-Use Building
Multi-Family/Apartment Building
Commercial Unit
Wooded Area
Wetlands
Lake/Pond
Ocean
Park/Playground
Other
Overall Condition of Exterior:
Please Select
Excellent
Good
Fair
Poor
Exterior Hazards:
*
Yes
No
List Exterior Hazards and Recommendations:
Write N/A or None if no Hazards. Provide photos for each hazard.
Interior:
Interior Walls:
Drywall
Plaster-lath
Wood Paneling
FRP Paneling
Brick
Concrete Block
Exposed Studs
Other
Ceiling:
Drywall
Plaster
Wood
Suspended Ceiling Tiles
Exposed/Open
Cathedral
Other
Flooring:
Hardwood
Tile
Vinyl
Engineered Hardwood
LVP
Carpet
Linoleum
Subfloor
Concrete
Other
Type of construction:
Average
Semi-Custom
Custom
Other
Overall Condition of Interior:
Excellent
Good
Fair
Poor
Interior Hazards:
Yes
No
List Interior Hazards
Write N/A or None if no Hazards. Provide photos for each hazard.
Utilities:
Heating Systems
Heating Fuel Types:
Natural Gas
Oil
Propane
Electric
Alternate Heat Source (fireplace/wood stove)
No Heat
No Access
Natural Gas Heating System(s):
Forced Hot Water
Forced Hot Air
Steam
Wall Monitor
Ceiling Unit
Hydro-Air
Radiant
Gas on Gas (Gas Log)
Parlor Stove
N/A
Other
Oil Heating System(s):
Forced Hot Water
Forced Hot Air
Steam
Hydro-Air
Radiant
N/A
Other
Electric Heating System(s):
Baseboard
Wall Monitors
Mini-Splits
Heat Pumps
Radiant
Ceiling Units
N/A
Other
Propane Gas Heating System(s):
Forced Hot Water
Forced Hot Air
Steam
Wall Monitor
Ceiling Unit
Hydro-Air
Radiant
Gas on Gas (Gas Log)
Parlor Stove
N/A
Other
Alternate Heating Source:
Wood Fireplace
Gas Fireplace
Gas Stove- Free Standing
Wood Stove
Pellet Stove
Insert (wood stove/pellet)
Solar
Geothermal Heat Pumps
No Heat
N/A
Other
Overall Condition of Heating Systems:
Excellent
Good
Fair
Poor
N/A
Other
Central Air Conditioning:
Yes
No
Mini-Splits
Other
Exterior Condenser Units:
Good Condition
Fair Condition
Poor Condition
Other
Plumbing
Supply Lines:
Copper
PEX
Galvanized Pipe
None
No Access
Other
Drain:
Cast Iron
PVC
ABS
Copper
Galvanized Pipe
None
No Access
Other
Water Heater:
Tank
Tankless
Hybrid
None
No Access
Other
Overall Condition of Plumbing:
Excellent
Good
Fair
Poor
N/A
Other
Sewer Main:
Town / City
Private Septic
Unknown
Other
Electrical
Electrical Panels:
Circuit Breakers
Fuses
Temporary Electrical Drop
No Access
Other
Panel Amperage:
60 Amps
100 Amps
125 Amps
150 Amps
200 Amps
400 Amps
No Access
Other
Number of Panels:
Please Select
One
Two
Three
Four
Five
Multiple
None
No Access
Wiring:
Romex
BX
Cloth Romex
MC
Conduit
No Access
Knob & Tube (HAZARD)
Other
Breaker Panel Manufacturer:
Challenger (Hazard)
Cutler-Hammer
Murray
Square D (Potential Hazard 2020-2022)
Siemens
Eaton
Bryant
General Electric
Crouse-Hinds
General Switch
Westinghouse
Bulldog-Pushmatic
I.T.E.
Levington
Federal Pacific (Stab-Lok Breakers) (Hazard)
Sylvania (Hazard)
No Access
Other
Square D Breaker Panel Date Code:
Overall Condition of Electrical:
Excellent
Good
Fair
Poor
No Access
Utility Updates
Natural Gas Heating System:
New
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
25-35 years
35-45 years
Original
Updating During Renovations
No access
N/A
Other
Oil Heating System:
New
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
25-35 years
35-45 years
Original
Updating During Renovations
No access
N/A
Other
Electric Heating System:
New
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
25-35 years
35-45 years
Original
Updating During Renovations
No access
N/A
Other
Propane Heating System:
New
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
25-35 years
35-45 years
Original
Updating During Renovations
No access
N/A
Other
Plumbing:
New
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
25-35 years
35-45 years
Original
Updating During Renovations
Partial Updates
No access
N/A
Other
Electrical:
New
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
25-35 years
35-45 years
Original
Updating During Renovations
Partial Updates
No access
Other
Water Heater:
New
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
Original
Updating During Renovations
No access
Tankless
Other
Utility Hazards:
Yes
No
List Utility Hazards:
Write N/A or None if no Hazards. Provide photos for each hazard.
Protection:
Residential Areas:
None
Smoke Detectors
Carbon Monoxide Detectors
Heat Detectors
Wet Sprinkler System
Dry Sprinkler System
Emergency Lighting
Illuminated Exit Signs
Exit Signs
Emergency Push Bars on Doors
Strobes/Klaxons
Fire Pull Stations
Video Surveillance
Security Grates
Fire Escape
Whole House Automatic Generator
Signage Posted (Private Property)
Signage Posted (No Trespassing)
Signage Posted (Construction Area)
Fenced Lot- Secured
Other
Commercial Areas:
None
Smoke Detectors
Carbon Monoxide Detectors
Heat Detectors
Wet Sprinkler System
Dry Sprinkler System
Emergency Lighting
Illuminated Exit Signs
Exit Signs
Emergency Push Bars on Doors
Strobes/Klaxons
Fire Pull Stations
Video Surveillance
Security Grates
Fire Escape
Whole House Automatic Generator
Signage Posted (Private Property)
Signage Posted (No Trespassing)
Signage Posted (Construction Area)
Fenced Lot- Secured
Other
Fire Extinguisher:
ABC
Class-K
None
Tagged
Date Tagged
Alarms:
Central Station Fire Alarm
Internal Fire Alarm (Not Monitored)
Fire Alarm Panel (Normal Operations)
Fire Alarm Panel (Trouble with System)
No Access to Fire Panel
Central Station Burglar Alarm
None
Other
Sprinkler System:
Up to date
Overdue for service
No tag
No access
None
Date Tagged
Distance to Fire Hydrant:
*
Within 50 feet
Within 100 feet
Within 200 feet
Within 500 feet
Within 1,000 feet
None
Suction Point
Other
Distance to Fire Department:
*
Within 500 feet
Within one mile
Within two miles
Within three miles
Within four miles
Within five miles
None
Other
Protective Hazards:
Yes
No
List Protective Measure Hazards:
Write N/A or None if no Hazards. Provide photos for each hazard.
Vacancy / Builders Risk / Secondary Residence:
How often is property checked?
The risk is checked daily
The risk is checked multiple times per week
The risk is checked weekly
The risk is checked bi-weekly
The risk is checked monthly
The risk is checked every 2-3 months
Other
If secondary residence, does the insured have a caretaker or property manager?
Yes
No
No, insured checks property
Other
Utilities Being Maintained:
Electric On
Plumbing On
Heating On
Electric Off
Plumbing Off
Heating Off
Winterized (heating/plumbing off, pipes drained)
No Utilities
Locked & Secure:
Yes
No
Other
Builders Risk Info
Fill out if building is under renovation or new construction
(New Construction Only) Square Footage of new construction:
(New Construction Only) What are they building?
Renovations being conducted:
Cosmetic
Full Rehab
Addition
Exterior Siding
Roofing
Windows
Interior walls/ceilings
Flooring
Kitchen
Bathroom(s)
Heating updates
Electrical updates
Plumbing updates
Other
Start Date:
Completion Date:
Estimate Project Costs:
General Contractor Name:
Percentage Subcontracted:
Type of License:
Construction Supervisors License
None
Other
Does the insured require certificates of insurance from contractors?
Yes
No
Other
Plans for Risk:
Sell
Rent
Owner occupied
Unkown at this time
Other
Additional Vacancy/Renovation information:
Homeowners:
The risk is a:
Primary Residence
Secondary Residence
Seasonal Residence
Rental Property
Other
Rented to others:
No
Yes
Year-round tenant
Seasonal tenant
1-5 weeks
5-10 weeks
Off season tenant
Other
No. Full Baths:
No. Half Baths:
Distance to Coastline:
Construction Type:
Average
Semi-Custom
Custom
Other
Dog on premises:
Unknown
No
Yes
Enter Breed
Replacement Cost Supplement:
Year Built:
Estimated Depreciation Age:
Based off updates to kitchen, baths, utilities, roof, etc.
Does the basement contain additional living area?
Yes
No
% Finished
Number of Kitchens
Number of Full Baths
Number of 3/4 Baths
Number of 1/2 Baths
Interior Flooring (list percentage for each)
Hardwood
Carpet
Tile
Vinyl
LVP
Engineered Wood
Laminated Wood
Other
%
Interior Ceilings (list percentage for each)
Drywall
Plaster
Suspended Tile
Wood
Wood Beams
Ceramic Tile
Tin
Other
%
Interior walls (list percentage for each)
Drywall
Plaster
Tile
Walpaper
Wainscoting
Board & Batten
Wood Paneling
Other
%
Additional Interior Features (list percentage for each)
Jacuzzi/hot tub
Spiral Staircase
Sauna
Wet Bar
Central Station Burglar Alarm
Central Vacuum
Skylights
Sliding Door
Number
Additional Exterior Features (list square footage for each)
Wood Deck
Composite Deck
Open Porch
Closed Porch
Other
Irrigation System
SF
Fireplace
Single Fireplace
Wood Stove
Pellet Stove
Gas Fireplace
Other
Number
Detached Structures
Sm Shed
Med Shed
Lg Shed
Built in BBQ
Other
Number
Additional Information for RC
Business:
Estimated Annual Gross Sales:
Content Value of Business & Personal Property (BPP):
Number of employees
Does the insured own the building:
Yes
No, the insured leases the location
Yes, under separate entity
Other
List additional business information here:
How long the insured has been in operation, etc...
Daycare Supplement:
Fill this out if the insured operates a daycare
Is the insured licensed?
Yes
No
Other
Are employees CORI cleared?
Yes
No
Other
Licensed for # children:
Playground equipment?
Yes
No
Other
Pick up / drop off policy?
Yes
No
Other
Does the insured provide transportation?
Yes
No
Other
Restaurant/Commercial Kitchen:
Seating Capacity:
Does the insured provide table service?
Yes
No
Other
Does the insured serve alcohol?
Yes
No
Other
Alcohol vs. Food sales percentage:
Does the insured provide live entertainment?
Yes
No
Occasionally
Weekends
Does the insured provide on-location catering services?
Yes
No
Occasionally
Other
Type of food served:
American Pub Food
Classic American (Dinner/Grills)
Southern / Soul Food
Cajun / Creole
Tex-Mex
BBQ
Steakouse
New England Seafood
Italian
Pizza / Sandwich Shop
Spanish / Tapas
Greek
German
Irish/British Pub Food
Mexican
Jamaican
Chinese
Japanese
Thai
Korean / Korean BBQ
Vietnamese
Indian
Asian Fusion
Middle Eastern
Kitchen Equipment:
Open flame grill
Flat top grill
Convection oven
Pizza oven
Oven
Deep Fat Fryer
Broiler
Wok
Pork upright oven
Other
Are cooking areas covered with a hood and exhaust system?
Yes
No
Other
Hood serviced by:
Hood service date:
Hood service up-to-date:
Yes
No
Other
Is the hood & exhaust system equipped with a fire suppression system:
Yes
No
Other
Suppression system serviced by:
Suppression system service date:
Suppression system service up-to-date:
Yes
No
Other
Kitchen housekeeping?
Excellent
Good
Fair
Poor
Other
List commercial kitchen hazards:
Liquor Liability:
Business hours of operation:
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Hours
Any catering services where the insured serve/sell alcohol?
Yes
No
Other
Number of staff that serve alcohol:
Have all servers been trained through approved server training course?
Yes
TIPS
TOPS
TAMS
No
Other
How often does the insured review liquor liability laws with employees:
Daily
Weekly
Monthly
Every few months
Yearly
As needed
Other
Are employees allowed to drink at the establishment?
Yes
No
Occasionally
Other
How is age of customer verified?
Government issued picture ID card
ID scanner used
Other
Type of clientele:
Area residents
Area workers
Tourists
College Students
Other
Is the risk located near a college campus?
Yes
No
Other
Is the risk located near a boat dock or marina?
Yes
No
Other
Is there a swimming pool exposure?
Yes
No
Other
Security Activities:
Bouncer
Contracted security firm
Police officer
Video Surveillance
Other
Firearms stored on premises?
No
Yes
Other
Submit
Submit
Office Use Only
Estimated Replacement Costs
Actual Cash Value
Exterior
Front (single picture for cover)
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Exterior Front:
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Exterior Sides:
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Exterior Rear:
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Roof:
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Additional Exterior:
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Outbuilding(s)
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Interior Residential
Kitchen:
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Bathroom(s):
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Basement:
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Additional Interior:
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Interior Common Areas (Multi-family/Mixed Use Only):
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Interior Commercial
Interior Commercial Photos
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Utilities
Heating & Cooling:
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Plumbing:
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Electrical:
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Water Heater:
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Solar / Other:
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Additional Utilities:
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Protective Residential Area
Protective Measures Residential Photos:
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Protective Commercial Area
Protective Measures Commercial Photos:
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Sprinkler System
Sprinkler System Photos:
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Swimming Pool / Hot Tub /Daycare License
Swimming Pool Photos:
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Hot Tub Photos:
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Daycare License Photo:
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Hazards & Recommendations
Click None if there are No hazards.
None
Yes
Hazard:
Hazard Photo:
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Hazard:
Hazard Photo:
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Hazard:
Hazard Photo:
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Hazard:
Hazard Photo:
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Hazard:
Hazard Photo:
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Hazard:
Hazard Photo:
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Additional Hazards and Concerns:
Additional Hazards Photo:
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Recommendation: Fire Extinguisher
Please Select
Keep an ABC fire extinguisher on-site for the duration of the renovations.
Keep an ABC fire extinguisher on-site for the duration of the construction.
Square D six digit date code Non Recall
Only enter if there's a six digit code
Square D Non Recall
Please Select
The Square D breaker panel date code(s) does not fall within the recall. No further action is required.
The Square D breaker panel appears to be original and does not contain a six digit date code. No further action is required.
The Square D breaker panel does not have a six digit date code. No further action is required.
The Square D breaker panel date code was not visible. The inspector was unable to verify if the panel falls within the recall.
The Square D breaker panel is original to the risk and not part of the recall.
Non Recall Square D Breaker Photo:
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Ai Automation:
Yes
No
Inspectors Invoice Only
Create Narrative
Company Fee:
$115
$150
$85
$65
Other
Inspection Type:
Exterior
Full
Exterior Island
Full Island
Other
Inspector Fee:
$27
$50
$55
$56
$60
$65
Other
Report Reviewed By:
William Bierce
Ashley Freudenthal
Other
Description of Risk:
Construction & Exterior Conditions:
Interior Conditions:
Utilities & Mechanical:
Protective Measures:
Business Supplement:
Vacancy/Builders Risk:
Underwriting Summary:
Print
Submit
Should be Empty: