Non-Owner Survey

Do Not Print.
Form must be completed online or by calling our toll free number at 1(800) 847-7030 and pressing extension 243 Monday through Friday 8:30am - 4:00pm est.
Date:
Insured's Name:
Policy #:
Phone:
911 Address (Physical Address of Property):
Person Interviewed:
Year Dwelling Built:
Purchased:
Number of Apartments?
Number of Occupants?
Is building managed? Yes   No
If yes, by whom?
Do you or any of your relatives occupy any of the apartments? Yes   No
If yes, how are they related?
What are tenants occupations and names of employers?
Is there a lease? Yes   No
Are tenants required to carry renters insurance? Yes   No
Are any of the units currently vacant? Yes   No
If yes, how long have they been vacant?
Is any work needed before they will be ready for occupancy? Yes   No
 
Decks? Yes  No
Height:
Age:
Condition:
Poor   Fair Good Excellent
Type of Materials:
 
Are there any other structures on the property? Yes   No
If yes, how are they used?
Any Student Housing? Yes   No
What arrangement is there for snow and ice removal?
Any business on the premises? Yes   No
If yes, please explain:
 
Pool:
None   Inground   Above Ground
Fenced  Locking Gate
 
Trampoline? Yes  No
Swing Set? Yes  No
Jungle Gym? Yes  No
Livestock (horses, cattle, etc.)? Yes  No
Livestock Type:
Livestock Number:
 
Dogs? Yes  No
Number of Dogs:
Breed (also needed if mixed):
Age of Dogs?
Dog Temperament?
Dogs Bite History? Yes  No
If yes, please explain:
Other Pets?
 
Fireplace? Yes  No
Woodstove? Yes  No
Woodfurnace? Yes  No
Frequency of Use:
Age of Central Heating System:
Heat Type:
Fuel Storage Tank? Yes  No
Fuel Tank Location:
Fuel Tank Inground? Yes  No
Fuel Tank Condition:
Do any of the units have space heaters? Yes  No
 
Electrical Service: Circuit Breakers  Fuses
Size of Electrical Entrance?
  Date By Whom (Insured, Contactor, NA)
Electrical Updated?
Plumbing Updated?
Heating Updated?
Roof Updated?
Additional Survey Comments:

IMPORTANT NOTICE TO POLICYHOLDER

"Any person who knowlingly 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 of the insurance to which this application is made. The Applicant, upon written request, will be informed whether or 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 are true to the best of his/her knowledge.