Property Insurance Request
BUILDING NAME ________________________________________________________________________
REQUESTED COVERAGE START DATE ________________________________________________________
_______________________________________________________________________________________
BUILDING DATA
1. No. of Stories/Avg. Height (ft)
______________________________
2. Year Built ______________________
3. Town Class (to be completed by
DORM)_________________________
4. Total Gross Square Footage (under roof
enclosed by 4 walls) _______________
5. List Additions such as open porch, builtin kitchen equip., interior bleacher
seating, mezzanines, etc.
________________________________
________________________________
_______________________________
6. Fire Protection (Check all that apply)
N
Y
• Fully Sprinklered
• Fire Extinguishers
Y
N
• Fire Alarm
Y
N
Central Station
Y
N
Local
Y
N
• Smoke Detectors
Y
N
•
If kitchen, is there a
hood extinguisher Y
N
7. Building Condition ( if over 5 years)
•
N
Rewired
Y
What Year? ___________
•
New Plumbing
Y
N
What Year? ____________
•
New Roof Installed Y
N
What Year? ____________
•
Remodeled
Y
N
What Year? ____________
8. Overall Building Condition (Select One):
Excellent
Good
Average
Poor
Name (Print/Type): ______________________________________________________________
Signature: ______________________________________________________________________
Title/Position: __________________________________________________________________
Email: ______________________________________________________________ __________
Telephone: ____________________________
Date: _________________________________
Construction Characteristics
1. FLOOR (ground level)
Concrete
12. CEILING FINISH
7. ROOF SUPPORTS
Wood
Drywall
Wood
Metal
Paint
Crawl Space
Concrete
Paneling, wood
Slits
Other _______________
Plastered, sprayed
2. UPPER FLOORS
Concrete
9. INTERIOR WALLS - Wall Structure
Brick, solid
Wood
Concrete block
Other __________________
3. UPPER FLOOR SUPPORT
Wood
Plywood/hardwood/fireberboard
13. HEAT SYSTEM
Coal
Studs, grits, etc.
Electric
None
Gas
Wood
10. WALL FINISH - Wall Structure
Concrete
Drywall
Metal
Paint
Solid brick or stone
Epoxy
Hollow concrete block
Other ___________________
14. HEAT METHOD
Forced
Hot Water
Paneling, solid wood
Radiant
All Metal
Plywood/hardwood/fiberwood
Tile, ceramic. or quarry
Solid Concrete
Wallpaper, vinyl
Other __________________
Hollow concrete block w/brick or stone ven.
4. EXTERIOR WALLS
Wood studs with wood siding
Wood studs with vinyl siding
None
11. FLOOR FINISH
Brick
Wood studs with metal siding
Carpet
Metal girts with brick veneer
Concrete sealer or topping
Woods with brick or stone veneer
Epoxy
Other _______________________
Hardwood
5. ROOF
Flat
Pitched
Combination
Other ______________________
6. ROOF DECK
Wood
Metal
Concrete
Tectum
Other _____________________
Steam
15. AIR CONDITIONING
Chilled water with air handlers
Chilled water with fan coil units
Evaporative coolers
Forced cool air
Heat pump
Other _________________
Linoleum
Marble
Synthetic gym floor
Terrazzo
Tile, ceramic, quarry, or rubber
Tile, vinyl composite
Vinyl Sheet
None
IMPORTANT!
1. Please sketch the ground floor with
dimensions or send copy of floor plan with
this form.
2. Take 2-3 exterior AND intereior photos
with a digital camera and email to us as
JPEG. Please DO NOT fax picture files.
3. Print this completed form, and then scan
and email or fax to:
USA Risk Management & Insurance Dept.
cgcook@southalabama.edu
FAX: (251) 460 - 6074