LESSORS RISK SUPPLEMENTAL QUESTIONNAIRE

Quote #
Applicant is:
INDIVIDUAL
JOINT VENTURE
PARTNERSHIP
CORPORATION
OTHER
If other, please specify
Name of applicant
Location Address
Effective Date:
Expiration Date
Construction:
Area:
Parking
# of Stories:
Total area leased (sq. ft)
Total sq. ft. for lease now vacant
Describe the type of tenants anticipated to rent this vacant space:
Completely describe the Tenant(s) operations at this location
Does the insured have a financial interest in any of these tenant operations?
YesNo
(If Yes, Explain)
Any vacancies adjoining this risk?
YesNo
(If Yes, Explain)
Electrical System protected by
Circuit BreakersFuses
Indicate the type of fire protection equipment on premises?
Fire Extinguishers
Smoke Detectors
Sprinklers
Other
If other explain
Heating system is
Gas Electric
If Gas, are heaters properly vented?
YesNo
Indicate type of alarm on premises:
Fire
Burglar
Local Alarm
Central Station
None
Name of Alarm Company:
Phone:
Is there cooking on the premises?
YesNo
Is there automatic fire suppression service at least every 90 days?
YesNoNot Applicable
If no explain
Are there high temperature limit cut off switches on all deep fat fryers and ovens?
YesNo
LANDLORD INFORMATION
Is landlord named as Additional Insured under tenants general Liability policy?
YesNo
Insured must have Certificates of Insurance on file at time of Inspection.
YesNo
Is there an Indemnity & Hold Harmless Agreement between landlord and tenant?
YesNo
Does the insured allow special events or exhibits on premises?
YesNo
If yes explain
Own other properties not covered under this policy?
YesNo
Has the applicant been non-renewed or refused coverage in the last three years?
YesNo
Has agent seen the risk in the last 60 days?
YesNo
What is the overall condition?
Please Explain Any Yes Responses:
 
NOTE:  Before transmitting this form via our website, please print a copy for your records and for the insured's signature.  We require that the insured sign this form and for the signed copy to be faxed to our office prior to binding.  Please note that coverage can't be bound or amended via this website.  You must receive a binder or written confirmation from our office for coverage to be bound.
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