Non-Owner Occupied Survey

Insured's Name

First NameLast Name

Date

MonthDayYear

Policy #

Email

example@example.com

911 Address (Physical Address of Property)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

Person Interviewed

Year Dwelling was Built

Year Purchased

Number of Apartments

Number of Occupants

Any Smokers in the Home?

YesNo

If yes:

CigarettesCigarsPipesOther

Any Working Smoke Detectors in the Home

YesNo

If Yes: How many?

Type of Smoke Detector

BatteyHardwired

Any Working Fire Extinguishers in the Home

YesNo

If Yes: How many?

Any Working Carbon Monoxide Detectors in the Home

YesNo

If Yes: How many?

Type of Carbon Monoxide Detectors

BatteyHardwired

Is the building managed?

YesNo

If yes, by whom?

Do you or any of your relatives occupy any of the apartments?

YesNo

If yes, how are they related?

What are the tenants occupations and names of employers?

Is there a lease?

YesNo

Are Tenants required to carry renters insurance?

YesNo

Are any of the units currently vacant?

YesNo

If yes, how long have they been vacant?

Is any work needed before they will be ready for occupancy?

YesNo

Any student housing?

YesNo

Any business on the premises?

YesNo

If yes, please explain:

Electrical Service

Circuit BreakersFusesBoth Circuit Breakers & FusesNo Electrical Service

Size of Electrical Entrance

Amps

Electrical Updated?

Year

By Whom?

(Insured, Contractor, Other)

Plumbing Updated?

Year

By Whom?

(Insured, Contractor, Other)

Heating Updated?

Year

By Whom?

(Insured, Contractor, Other)

Roof Updated?

Year

By Whom?

(Insured, Contractor, Other)

Pool:

IngroundAbove GroundNone

If Yes

FencedLocking Gate

Trampoline?

YesNo

Swing Set?

YesNo

Livestock (horses, cattle, etc.)?

YesNo

Livestock Type:

Livestock Number:

Dogs?

YesNo

Number of Dogs:

Breed (also needed if mixed):

Age of Dogs:

Dog Temperament:

Dog Bite History?

YesNo

If yes, please explain:

Other pets?

Fireplace?

YesNo

Pelletstove?

YesNo

Woodstove?

YesNo

Woodfurnace?

YesNo

Woodboiler?

YesNo

Frequency of Use

Age of Central Heating System?

Heat Type?

Fuel Storage Tank?

YesNo

Fuel Tank Inground?

YesNo

Fuel Tank Size?

Fuel Tank Type?

Fuel Tank Location?

Fuel Tank Condition?

Do any units have space heaters?

YesNo

Decks?

YesNo

Height:

Age:

Type of Materials:

Condition?

ExcellentGoodFairPoor

Are there any other structures on premises?

YesNo

If yes, what are they used for:

What arrangement is there for snow and ice removal:

Additional Survey Comments/Questions:

IMPORTANT NOTICE TO POLICYHOLDER

"Any peson who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."

As part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal, or extension othe insurance to which this application is made. The applicant, upon written request, will be informed whetheror not a consumer report was requested - and if such was requested, informed of the name and address of the consumer reporting agency that furnished the report. The person completing this survey hereby affirms that the statements and representations made herein ae true to the best of his/her knowledge.