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Property Insurance Underwriting Survey
General Information:
Exact Name of Applicant:
Submitted Date:
Effective Date:
Street or P.O. Box:
City:
State:
Select One
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Contact:
Telephone:
Email:
Business or occupation of applicant:
Property Description & Coverage Schedule:
Location or Building #1
Location or Building #2
Location or Building #3
Building
$
$
$
Contents
$
$
$
Tools
$
$
$
Misc. Equipment
$
$
$
Employee Tools
$
$
$
EDP Equipment
$
$
$
Area in Square Feet
Type Construction-Bldg.
Type Construction-Roof
Year Construction-Bldg.
Airport Name:
Identifier:
Address of Building:
Airport Fenced:
Yes
No
Alarm System:
Yes
No - Type:
Fire Department on Airport:
Yes
No
Distance to Fire Department:
Tower:
Yes
No - Hours:
Repair and Service Work in Hanger:
Yes
No
Describe:
Painting in Hanger:
Yes
No
Describe:
Occupancy
(type of contents kept in building):
Name and Address of Mortgagee:
Prior Insurance (Last 3 years):
Policy Term
Name of Company
Policy Number
Premium
Loss Detail (Last 3 years):
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