Casey Insurer Services
Homeowners Form
Company:
*
Jencap
DeCotis Insurance - MA
DeCotis Insurance - RI
Johnson & Johnson Insurance
Market Finders Insurance
Jencap/Quaker Special Risk
Safety Insurance
Insured Name:
*
Policy #:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency:
*
Inspector's Name:
*
William Bierce
Keith McEachern
Bill Casey
John Frank
Jim McEachern
David Morin
Ashley Freudenthal
Nicole Messier
Charles Lyons
Greg McEachern
Mark Kramer
Gregg Barney
Dick Herman
Matt Bodman
Tyler McQuade
Latania Knights
Kristian Mahaffey
Austin Giese
Erick Hartz
Inspection Date:
*
-
Month
-
Day
Year
Date Picker Icon
Met With:
*
Insured
Owner
Property Manager
Tenant
Caretaker
Employee
Friend
Business Partner
Realtor
Contractors
Family Member
Husband
Wife
Mother
Father
Son
Daughter
NO SHOW- see last page
No Show
Lock Box
Left Open
Left Key for Inspector
Exterior Only
Person you met with
Contact Name:
*
First Name
Last Name
Contact Information:
Additional phone numbers and email addresses
Type of Risk/Description:
*
Total Living Square Footage:
*
Owned Property:
*
Prior Loss:
*
Yes
No
Unknown
Prior Loss Description:
Replacement Cost Required?
*
Yes
No
The risk is a:
*
Primary Residence
Secondary Residence
Seasonal Residence
Rental Property
Other
Rented to others:
*
No
Yes
Year-Round Tenant
1-5 Weeks
5-10 Weeks
Seasonal Tenant
Off-Season Tenant
Other
No. Rooms:
*
No. Full Baths:
*
No. Half Baths:
*
Estimated Replacement Costs:
Enter Dollar Amount
Estimated Valuation:
Enter Dollar Amount
Agree with R/C?
Yes
No
Other
Construction Type:
*
Average
Semi-Custom
Custom
Other
Click here for NO SHOW
Contacted Insured Via:
Phone
Phone Voicemail
Text Message
Email
Other
Date:
-
Month
-
Day
Year
Date
Contacted Insured Via:
Phone
Phone Voicemail
Text Message
Email
Other
Date:
-
Month
-
Day
Year
Date
Contacted Insured Via:
Phone
Phone Voicemail
Text Message
Email
Other
Date:
-
Month
-
Day
Year
Date
Was agency contacted by inspector?
Yes
No
Other
Date Agency Contacted:
-
Month
-
Day
Year
Date
Agent's Name
First Name
Last Name (if you have it)
The insured
was unresponsive
confirmed the appointment but did not show
Other
Additional Information:
Additional information regarding the no show
Area/Type of Neighborhood
Area
Type of Neighborhood
*
Residential
Commercial
Industrial
Area
*
Urban
Suburban
Rural
Area Security/Safety
*
Good
Fair
Poor
Click Here For Construction
Construction
Age of Building:
*
120 Years Old
# of Stories:
*
1
1.5
2
2.5
3
3.5
4
4.5
5
6
7
8
9
10+
Foundation:
*
Concrete
Brick
Fieldstone
Concrete Block
Concrete Slab
Crawl Space
Pylons
Stone Block
Other
Basement Usage:
*
Finished Area
Utilities
Storage
No Basement
Other
Exterior Frame:
*
Wood Frame
Steel Frame
Concrete Block
Brick
Other
Exterior Siding:
*
Vinyl
Wood Clapboard
Wood Shingles
Fiber Cement Clapboard
Brick
Concrete Block
Aluminum
Asbestos Shingles
Asphalt Shingles
Stucco
Steel Sheathing
T1-11 Wood Siding
Vinyl Shake Shingles
Other
Roof Type:
*
Flat
Gable
Hip
Mansard
Gambrel
Sloped
Other
Roof Deck:
*
Wood
Steel
Concrete
Other
Roof Covering:
*
Asphalt Shingles
Rubber Membrane
Tar & Gravel
Wood Shake
Slate
Metal
Other
Roof Age:
*
New
Less than one year
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
25 + years
Original
Unknown/Not Visible
Other
Interior Walls & Ceilings:
*
Wood Frame
Steel Frame
Concrete Block
Brick
Wall Covering:
*
Drywall
Plaster-lath
Wood Paneling
Millwork
Brick
Exposed/Studs
Other
Ceiling:
*
Drywall
Plaster
Suspended
Wood
Tin
Tile
Exposed/Open
Other
Flooring:
*
Wood Joists
Concrete
Steel Supports
Floor Coverings:
*
Hardwood
Tile
Carpet
Vinyl
Concrete
LVP (Luxury Vinyl Plank)
Linoleum
Stone
Subflooring
Engineered Hardwood
Other
Off Street Parking:
*
No
Yes
Other
Garage:
*
None
Attached 1 Car
Attached 2 Car
Attached 3 Car
Detached 1 Car
Detached 2 Car
Detached 3 Car
One Car Under
Two Car Under
Other
Overall Condition of Building:
*
Excellent
Good
Fair
Poor
Click Here For Utilities
Utilities
Heating/Cooling System(s):
*
Gas Forced Hot Water
Oil Forced Hot Water
Gas Forced Hot Air
Oil Forced Hot Air
Gas Steam
Oil Steam
Gas/Electric HVAC
Electric Baseboard
Electric Wall Monitor
Gas Wall Monitor
Gas Ceiling Unit
Electric Ceiling Unit
Gas on Gas
Gas Parlor Stove
Wood Stove
Pellet Stove
Wood Fireplace
Gas Fireplace
Gas Radiant
Electric Split Air System
Gas Hydro-Air System
Central Air Conditioning
No Heat
No Access
Other
No. Heating Units:
*
None
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Multiple
Unknown
Type of Plumbing:
*
Copper
Cast Iron (gas line)
Cast Iron (waste line)
PVC
PEX
Flex Pipe
ABS
Brass
No Access
Other
Electrical:
*
Breakers
Fuses
No Access
Challenger
Federal Pacific (Stab-Lok Breakers)
Zinsco or Zinsco-Sylvania
Murray Electric
Scott Electric Co
Square D
Siemens
Eaton
Cutler-Hammer
Bryant
General Electric
Crouse Hinds
Westinghouse
Bulldog Pushmatic
I.T.E.
Leviton
Other
Does the risk have a Square D breaker panel?
*
Yes
No
Other
If yes, enter date code (examples below)
Amperage:
*
60
100
125
200
400
No Access
Other
No. Electrical Panels:
*
No Access
Multiple
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Electrical Wiring:
*
Romex
BX
Cloth Romex
MC
Commercial Cable
No Access
Other
Active Knob & Tube:
*
No
No Interior Access
Yes
Other
Utility Updates
Heating:
*
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
No Access
Other
Heating (System 2):
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
No Access
Other
Heating (System 3):
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
No Access
Other
Heating (System 4):
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
No Access
Other
Plumbing:
*
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
Partial Updates
No Access
Other
Electrical:
*
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
Partial Updates
No Access
Other
Hot Water Tank:
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Original
Tankless
No Access
Other
Septic System:
*
Yes
No
Unknown
Overall Utility Condition:
*
Good
Fair
Poor
N/A
Utility Hazards:
*
Yes
No
Click For Protection
Protective Measures:
*
Hardwired Smoke Detectors
Hardwired Carbon Monoxide Detectors
Battery Smoke Detectors
Battery Carbon Monoxide Detectors
Plug-In Carbon Monoxide Detectors
Video Surveillance
Heat Detectors
Whole House Automatic Generator
No Interior Access
None
Other
Alarms:
Burglar
Fire (Smoke & Carbon)
Temperature
Other
Utilities Maintained During Off- Season:
Yes
No
No, utilities are winterized
Other
Caretaker:
Yes
No
Insured checks property
Other
If Secondary residence, how often is property checked:
Multiple Times Per Week
Weekly
Bi-Weekly
Monthly
Every Few Months
Every Six Months
Yearly
Other
Rain Gutters Cleaned Yearly:
*
Yes
No
N/A
Other
Insured Has A Dog:
*
No
Yes
Other
Fire Extinguisher:
ABC
K-Class
Tagged
Other
Fire Hydrant:
*
Within 50 Feet
Within 100 Feet
Within 200 Feet
Within 500 Feet
None
Suction Point
Other
Fire Department:
*
Paid
Volunteer
Within 500 Feet
Within 1 Mile
Within 2 Miles
Within 3 Miles
Within 5 Miles
None
Other
Click for Replacement Cost Supplement
Year Built:
Depreciation Age:
Type of Construction:
Average
Semi-Custom
Custom
Basement Usage:
Full Size
Utilities
Slab
Crawl Space
Pylons
Additional Living Area
Other
Exterior Siding:
Vinyl
Alum
Clapboard
Wd Shake
Brick
Stucco
Cement Fiber Clapboard
Asbestos
Stone
Other (note below)
%
Roofing:
Architectural Shingles
3-Tab
Rubber
T&G
Wd Shake
Slate
Metal
%
Exterior Features:
Atrium Window
Bay Window
Bow Window
Picture Window
Sm. Skylight
Lg. Skylight
Sliding Door
Number
Kitchen:
Basic
Builders Grade
Semi-Custom
Custom
Designer
Number
Full Bathroom:
Basic
Builders Grade
Semi-Custom
Custom
Designer
Number
3/4 Bathroom:
Basic
Builders Grade
Semi-Custom
Custom
Designer
Number
1/2 Bathroom:
Basic
Builders Grade
Semi-Custom
Custom
Designer
Number
Wall Finish:
Paint
Wallpaper
Wood Paneling (sheet)
Knotty Pine
Solid Wood
Mirrors
Built-Ins
Custom Millwork
Tile
%
Ceiling Finish:
Drywall
Plaster
Wood
Acoustical Tile
Tin
%
Floors:
Hardwood
Carpet
Vinyl
Ceramic Tile
Laminated Wood
Rubber
Marble
%
Interior Features:
Central Station Burglar Alarm
Interior Sprinkler System
Central Vacuum
Intercom System
Central Stereo
Surveillance System
Additional Interior Features
Hot Tub
Wet Bar
French Doors
Jacuzzi
Spiral Staircase
Custom Vanity
Sauna
Number
Fireplaces:
Wood Stove
Single Fireplace
Double Fireplace
Gas Fireplace
Pellet Stove
Number
Attached Structures:
Wood Deck
Composite Deck
Open Porch
Closed Porch
Open Breezeway
Closed Breezeway
Square Footage
Detached Structures:
Sm Shed
Med Shed
Lg Shed
Hot Tub
Above Ground Swimming Pool
In-Ground Swimming Pool
BBQ
Tennis Court
Number
Addition Items/Information
Click Here For Swimming Pool
Swimming Pool:
*
Yes
No
Swimming Pool Type:
In-Ground
Above Ground
Diving Board
Water Slide
Other
Security of Area:
Secured
Fenced With Locked Gate
Not Secure
Rules/Signs Posted
Lifeguard
Other
Hot Tub:
Yes
No
Other
Click for Weather Exposure
Distance to Coastline:
*
Enter Feet or Miles
Click Here To List Hazards
Hazards & Recommendations
HAZARDS & RECOMMENDATIONS:
*
Yes - See below.
None
Hazard 2025-01:
Recommendation:
Hazard One Photo:
Browse Files
Cancel
of
Hazard 2025-02:
Recommendation:
Hazard Two Photo:
Browse Files
Cancel
of
Hazard 2025-03:
Recommendation:
Hazard Three Photo:
Browse Files
Cancel
of
Hazard 2025-04:
Recommendation:
Hazard Four Photo
Browse Files
Cancel
of
Hazard 2025-05:
Recommendation:
Hazard Five Photo:
Browse Files
Cancel
of
Hazard 2025-06:
Recommendation:
Hazard Six Photo
Browse Files
Cancel
of
Additional Hazards/Concerns:
Additional Hazard Photos:
Browse Files
Cancel
of
Click to upload Photos.
Front Exterior Pictures:
Browse Files
Cancel
of
Side Exterior Pictures:
Browse Files
Cancel
of
Rear Exterior Pictures:
Browse Files
Cancel
of
Roof Pictures:
Browse Files
Cancel
of
Additional Exterior Pictures:
Browse Files
Cancel
of
Outbuilding Pictures:
Browse Files
Cancel
of
Interior Pictures:
Browse Files
Cancel
of
Kitchen Pictures:
Browse Files
Cancel
of
Bathroom Pictures:
Browse Files
Cancel
of
Heating & Cooling Pictures:
Browse Files
Cancel
of
Electrical System Pictures:
Browse Files
Cancel
of
Hot Water Heater Pictures:
Browse Files
Cancel
of
Additional Utility Pictures:
Browse Files
Cancel
of
Protective Measure Photos:
Browse Files
Cancel
of
Swimming Pool Photos:
Browse Files
Upload Swimming Pool photos, locked gate, etc.
Cancel
of
Submit Order Form
Submit
Should be Empty: