Habitational Questionnaire

Producer

Producer Email *

Applicant

Other

Phone

Applicant Email

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Premise Address (1) *

Address Line 1

Address Line 2

City

State

Zip Code

Building Area (sq. ft.)

Property Type *

Single Family
Multi-Family (2-20 units)
Condo
Mobile

Number of Total Units

Construction Type

Year Built

Roof:

Update Information (if >25 years):

Electric:

Update Information (if >25 years):

Plumbing:

Update Information (if >25 years):

HVAC:

Update Information (if >25 years):

Occupancy Status

Coverage and Limits

Building:

Loss of Rents:

Business Personal Property:

Premise Address (2)

Address Line 1

Address Line 2

City

State

Zip Code

Building Area

Property Type

Single Family
Multi-Family (2-20 units)
Condo
Mobile

Number of Total Units

Construction Type

Year Built

Roof:

Update Information (if >25 years):

Electric:

Update Information (if >25 years):

Plumbing:

Update Information (if >25 years):

HVAC:

Update Information (if >25 years):

Occupancy Status

Coverage and Limits

Building:

Loss of Rents:

Business Personal Property:

Premise Address (3)

Address Line 1

Address Line 2

City

State

Zip Code

Building Area (sq. ft.)

Property Type

Single Family
Multi-Family (2-20 units)
Condo
Mobile

Number of Total Units

Construction Type

Year Built

Roof:

Update Information (if >25 years):

Electric:

Update Information (if >25 years):

Plumbing:

Update Information (if >25 years):

HVAC:

Update Information (if >25 years):

Occupancy Status

Coverage and Limits

Building:

Loss of Rents:

Business Personal Property:

Are there any common areas available for use by more than one tenant?

Yes
No

Does the attached parking available exceed 2,000 square feet or 24 spaces?

Yes
No

Are any commercial operations occurring on the premises?

Yes
No

Is this location professionally managed?

Yes
No

Does any commercial cooking occur on the premises?

Yes
No

Is there a pool, hot tub, and/or spa at this location?

Yes
No

Is the porch or roofline sagging?

Yes
No

Are functioning smoke detectors installed?

Yes
No

Are there any structural issues?

Yes
No

Is this location used as a vacation or seasonal rental?

Yes
No

Does the property have (either) Knob And Tube or Aluminum wiring?

Yes
No

Is this location used as a vacation or seasonal rental?

Yes
No

Does the location contain a wood-burning stove?

Yes
No

Is this lender placed coverage or a non performing note?

Yes
No

Are there any detached structures on the property?

Yes
No

Is the location leased to students?

Yes
No

Note: TPP coverage is required when the location leased to students is answered by "YES".

Is Renters Insurance required?

Yes
No

Are there any existing city/state housing code violations associated with this property?

Yes
No

Are there any local/state rental law, code or statute violations associated with this property?

Yes
No

Are locks changed or replaced upon a tenant leaving?

Yes
No

Are there any existing damage or maintenance issues at this property?

Yes
No

Does the location have a wood shake roof?

Yes
No

Are the heating, electrical and plumbing systems serviced by a qualified trade professional?

Yes
No

Does the property have Exterior Insulating Finishing Systems (EIFS) on supporting structures?

Yes
No

Does the property have Exterior Insulating Finishing Systems (EIFS) on supporting structures?

Yes
No

Is the property on stilts? (not including crawlspaces)

Yes
No

Does the property have an elevator, lift or hoist on premises?

Yes
No

Is location greater than 2 stories?

Yes
No

Would you like to add the tenant protector plan to this location?

Yes
No

Optional Coverages

Would you like to add Equipment Breakdown coverage?

Yes
No

Optional Coverages

Would you like to add Flood coverage?

Yes
No

Optional Coverages

Would you like to add PMEO coverage?

Yes
No

Optional Coverages

Would you like to add Service Line coverage?

Yes
No

Optional Coverages

Would you like to add Terrorism & Political Violence?

Yes
No

Optional Coverages

Would you like to add Ordinance or Law coverage?

Yes
No

Optional Coverages

Applicant's Signature *

Applicant Name *

First

Last

Title *

Date *

Producer's Signature *

Producer Name *

First

Last

Title *

Date *