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- | 0 J ' h h 4 h P - g u u u X u u u J u u u u d d d $E V DB d d d V d d d P P P P P P 60 Cutter Mill Road ( Suite 414
Great Neck, NY 11021
516-466-4200( HYPERLINK "http://www.butwin.com/allstate/index.htm"www.butwin.com
fax 516-466-4213 no cover page needed
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HYPERLINK "http://www.butwin.com/allstate/index.htm"HABITATIONAL
APPLICATION
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Applicants Name: FORMTEXT D B A : F O R M T E X T M a i l i n g A d d r e s s : F O R M T E X T P r o d u c e r F O R M T E X T C i t y , S t a t e , Z i p : F O R M T E X T C o n t a c t F O R M T E X T F O R M T E X T C o u n t y : F O R M T E X T F O R M T E X T F O R M T E X T E - m a i l F O R M T E X T F O R M T E X T F O R M T E X T T o w n s h i p : ( S t a t e o f P A o n l y ) F O R M T E X T F O R M T E X T F O R M T E X T P h o n e F O R M T E X T F O R M T E X T F O R M T E X T C o n t a c t & P h o n e : F O R M T E X T F O R M T E X T F a x F O R M T E X T F O R M T E X T E - m a i l & W e b s i t e : F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T
F O R M C H E C K B O X C o r p o r a t i o n F O R M C H E C K B O X P a r t n e r s h i p F O R M C H E C K B O X I n d i v i d u a l F O R M C H E C K B O X L L C F O R M C H E C K B O X O t h e r ( e x p l a i n ) F O R M T E X T F O R M C H E C K B O X C o n d o F O R M C H E C K B O X C o - o p F O R M C H E C K B O X R e n t a l B u i l d i n g A d d r e s s ( i f d i f f e r e n t f r o m m a i l i n g a d d r e s s ) : F O R M T E X T I H E R E B Y C E R T I F Y T H A T A L L L O C A T I O N S D O N O T C O N T A I N A N Y O F T H E F O L L O W I N G I N E L I G I B L E R I S K S : H O M E L E S S S H E L T E R S ; TEMPORARY SHELTERS; EMERGENCY SHELTERS; SUBSTANCE ABUSE PROGRAMS; MENTAL HEALTH FACILITIES; SROs (SINGLE ROOM OCCUPANCY); FRATERNITY OR STUDENT HOUSING; ANY NON-PROFIT CITY OR STATE SPONSORED SOCIAL SERVICE ENTITY, AGENCY, OR AFFILIATION FORMCHECKBOX Yes FORMCHECKBOX No Number of Units: FORMTEXT # O c c u p i e d : F O R M T E X T D o e s O w n e r R e s i d e o n P r e m i s e ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o M e r c a n t i l e / C o m m e r c i a l O c c u p a n c i e s ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o I f Y e s , i s T h e r e C o o k i n g ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o O c c u p a n c y D e s c r i p t i o n : F O R M T E X T S q u a r e F e e t : F O R M T E X T N u m b e r o f B u i l d i n g s : F O R M T E X T A n n u a l R e n t a l I n c o m e : $ F O R M T E X T ( N / A i f c o n d o ) C e r t i f i c a t e o f I n s u r a n c e o n f i l e f o r m e r c a n t i l e ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X N / A R E Q U I R E D % o f B u i l d i n g O c c u p i e d F O R M T E X T % B u i l d i n g T o t a l S q u a r e F o o t a g e : F O R M T E X T Y e a r B u i l t : F O R M T E X T A n y V a c a n t B u i l d i n g s o r L o t s o n Either Side of Your Building? FORMCHECKBOX Yes FORMCHECKBOX NoConstruction Type: FORMCHECKBOX Frame FORMCHECKBOX Brick/Joisted Masonry FORMCHECKBOX Non-Combustible FORMCHECKBOX Masonry Non-Comb. FORMCHECKBOX Fire-resistive
Is Roof Material Shake or Wood Shingle? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, Treated with Fire Retardant Material? FORMCHECKBOX Yes FORMCHECKBOX NoBasement Finished? FORMCHECKBOX Yes FORMCHEC K B O X N o # o f S t o r i e s a b o v e B a s e m e n t L e v e l ? F O R M T E X T # o f E l e v a t o r s : F O R M T E X T E l e v a t o r M a i n t a i n e d b y : F O R M T E X T I s E l e v a t o r M a i n t e n a n c e C e r t i f i c a t e o n F i l e ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o ( i f y e s , p r o v i de a copy)Dead Bolts? FORMCHECKBOX Yes FORMCHECKBOX NoFire Extinguishers? FORMCHECKBOX Yes FORMCHECKBOX NoFire Escapes? FORMCHECKBOX Yes FORMCHECKBOX NoBX Elec. Wiring? FORMCHECKBOX Yes FORMCHECKBOX NoIntercoms? FORMCHECKBOX Yes FORMCHECKBOX NoEmergency Lighting? FORMCHECKBOX Yes FORMCHECKBOX NoCircuit Breakers? FORMCHECKBOX Yes FORMCHECKBOX NoSmoke Detector in All Units? FORMCHECKBOX Yes FORMCHECKBOX NoCarbon Monoxide Detectors in All Units? FORMCHECKBOX Yes FORMCHECKBOX NoHard-Wired? FORMCHECKBOX Yes FORMCHECKBOX NoBattery? FORMCHECKBOX Yes FORMCHECKBOX NoIf Battery, is There a Battery Replacement Program? FORMCHECKBOX Yes FORMCHECKBOX NoSprinklers? FORMCHECKBOX Yes FORMCHECKBOX No% of Building Sprinklered? (describe) FORMTEXT I s s p r i n k l e r m a i n t a i n e d ? F O R M T E X T P l e a s e p r o v i d e c e r t i f i c a t e . B u r g l a r A l a r m ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o C e n t r a l S t a t i o n A l a r m ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o I s T h e r e a G a r a g e ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o I f Y e s , A t t a c h e d ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o G a r a g e S q u a r e F o o t a g e : F O R M T E X T I s I t U s e d f o r C o m m e r c i a l P u r p o s e s ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o I f Y e s , e x p l a i n : F O R M T E X T A r e S t a i r w a y s S teel or Steel Reinforced? FORMCHECKBOX Yes FORMCHECKBOX NoPAGE 1 OF 3
Butwin Insurance Group 60 Cutter Mill Road ( Suite 414
Great Neck, NY 11021
516-466-4200( HYPERLINK "http://www.butwin.com/allstate/index.htm"www.butwin.com
HABITATIONAL
APPLICATION
Any Building Violations? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, please describe: FORMTEXT A n y U n c o r r e c t e d T y p e B o r C B u i l d i n g V i o l a t i o n s i n t h e P r i o r T h r e e ( 3 ) Y e a r s ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o H o w M a n y U n i t s h a v e C h i l d r e n U n d e r t h e A g e o f T e n ( 1 0 ) Y e a r s R e s i d i n g o n P r e m i s e s ? F O R M T E X T D o Y o u A s k i f A n y Children Under Age Ten (10) Reside on Premises When a Lease is Signed? FORMCHECKBOX Yes FORMCHECKBOX NoDo You Send an Annual Notice to All Tenants Asking if Any Children Under Age Ten (10) Reside on Premises? FORMCHECKBOX Yes FORMCHECKBOX NoAre All Units with Children Under Age Ten (10) Visually Inspected at Lease Signing and Annually? FORMCHECKBOX Yes FORMCHECKBOX NoAre These Units Equipped with Child Window Guards? FORMCHECKBOX Yes FORMCHECKBOX NoAre There Any Dogs on the Premises? FORMCHECKBOX Yes FORMCHECKBOX NoAuthorized on Lease? FORMCHECKBOX Yes FORMCHECKBOX NoAre There Any Swimming Pools Including Wading Pools? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, are There Any Slides? FORMCHECKBOX Yes FORMCHECKBOX NoAny Diving Boards? FORMCHECKBOX Yes FORMCHECKBOX NoAny Armed Guards? FORMCHECKBOX Yes FORMCHECKBOX NoRENOVATIONSMUST BE REPORTED!Any Renovations Currently Under W a y o r P l a n n e d W i t h i n t h e N e x t T h r e e ( 3 ) Y e a r s ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o ( i f y e s , p l e a s e d e s c r i b e ) :
F O R M T E X T I n d i c a t e Y e a r N e x t t o E a c h B u i l d i n g U p d a t e : R o o f : F O R M T E X T H e a t i n g : F O R M T E X T W i n d o w s : F O R M T E X T E l e c t r i c a l : F O R M T E X T P l u m b i n g : F O R M T E X T O t h e r : F O R M T E X T * * I f s y s t e m s a r e o v e r 2 0 y e a r s o l d , p l e a s e a n s w e r t h e f o l l o w i n g f i v e ( 5 ) q u e s t i o n s 1 ) E l e c t r i c a l C O N D I T I O N F O R M C H E C K B O X E x c e l l e n t F O R M C H E C K B O X Good FORMCHECKBOX Fair FORMCHECKBOX Needs Improvement FORMCHECKBOX Fuses FORMCHECKBOX Circuit Breakers2) Heating SystemCONDITION FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX Needs ImprovementCentral Heat? FORMCHECKBOX Yes FORMCHECKBOX NoAge of Furnace: FORMTEXT S e r v i c e C o n t r a c t ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o F i r e p l a c e s ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o I f y e s , h a v e t h e y b e e n r e l i n e d ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o 3 ) P l u m b i n g & F i x t u r e s C O N D I T I O N F O R M C H E C K B O X E x c e l l e n t FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX Needs ImprovementType of Pipes: FORMCHECKBOX Copper FORMCHECKBOX Galvanized FORMCHECKBOX Plastic FORMCHECKBOX Mixed4) RoofCONDITION FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX Needs ImprovementType: FORMCHECKBOX Flat FORMCHECKBOX Pitches FORMCHECKBOX MixedYear Replaced: FORMTEXT Y e a r R e p a i r e d : F O R M T E X T Y e a r F u l l y / P r o p e r l y S e a l e d F O R M T E X T 5 ) W i n d o w s C O N D I T I O N F O R M C H E C K B O X E x c e l l e n t F O R M C H E C K B O X G o o d F O R M C H E C K B O X F a i r F O R M C H E C K B O X N e e d s I m p r o v e m e n t Y e a r R e p l a c e d : F O R M T E X T Y e a r R e p a i r e d : F O R M T E X T P R O P E R T Y S E C T I O N ( R E Q U E S T E D C O V E R A G E ) C o v e r a g e / A m o u n t C o - I n s u r a n c e F O R M C H E C K B O X 8 0 % F O R M C H E C K B O X 9 0 % F O R M C H E C K B O X 1 0 0 % F O R M C H E C K B O X A A V a l u a t i o n F O R M C H E C K B O X A C V F O R M C H E C K B O X R e p l a c e m e n t C o s t C a u s e s o f L o s s F O R M C H E C K B O X B a s i c F O R M C H E C K B O X S p e c i a l D e d u c t i b l e F O R M C H E C K B O X $ 1 , 0 0 0 F O R M C H E C K B O X $ 2 , 5 0 0 F O R M C H E C K B O X $ 5 , 0 0 0 F O R M C H E C K B O X $ 1 0 , 0 0 0 B u i l d i n g $ F O R M T E X T N a m e d S t o r m D e d u c t i b l e
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