Building & Content Insurance Underwriting Form
Please complete all applicable sections of this form.
Please attach a copy of the final inspection.
Please attach a copy of the Acceptance Form from the DOI.
Send completed form and supporting documentation EH&S, Loss Control & Insurance
Analyst
Building Name & Address:
________________________________________________________________________
________________________________________________________________________
New Building:
Date Accepted by State
Year Constructed
Construction Cost
_______________
_______________
$_______________
Acquisition:
Date of Acquisition
________________
Year Constructed
________________
Acquisition Cost
$_______________
Method of Acquisition:
__________Purchase
__________Transfer
__________Lease
__________Condemnation
__________Donation
__________Other
Renovation and/or Major Addition:
Date of Acceptance/Completion ______________
Renovation/Addition Cost
$______________
Renovation Type:
_______________ Add Space
_______________ Reduce Space
_______________ Total Number of Rooms
_______________ Original Square Footage
_______________ Increased Square Footage
_______________ Decreased Square Footage
Primary Building Usage:
(Office, Housing, Storage, Etc.)
_____________________________________
Building Occupant(s):
____________________________________
Gross Square Footage:
(The sum of all interior floor area(s))
__________________________________
National Historic Registry:
______________Yes ______________No
Total Number of Floors:
_________________Floors Above Ground
_________________Floors Below Ground
Fire Alarm:
______________Yes ______________No
Fire Sprinkler System:
______________Yes ______________No
Primary Responding Fire Department: __________________________________
Flood Zone:
(A, A1, B, C, V, X, etc.)
__________________________________
Heating System: Forced Air ___ Steam ___ Hot Water ___ Resist ___ Space Heater ___
None ___
Heating Fuel:
Electric ___ Gas ___ Fuel Oil ___ Coal ___ Wood ___ Solar ___
Other ___
A/C System:
Central ___ Window ___ None ___
Roof Construction: ______________________________________________________
Floor Material(s):
______________________________________________________
Exterior Wall Material(s):
Funding:
Building Coverage:
Content Coverage:
Requesting Agent:
________________________________________________
General ___ Special ___