Professional Documents
Culture Documents
Policy Number:
Location Address:
Agent:
City:
County:
State:
Zip Code:
Florida
_______________
_______________
Number of Stories:
_______________
SECTION I Dwelling
What is the primary construction
classification of the risk:
Frame
Unreinforced Masonry
Reinforced Masonry
Masonry Veneer
Fire Resistive
Monolithic Concrete (ICF)
Mixed ________________
Other ________________
SECTION II HVAC
Type of Heating Distribution System:
Air Vents
Radiators
Baseboard
In-Floor System
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Dishwasher
Refrigerator
Washing Machine
Water Heater
Showers/Tubs
Toilets
Sinks
Sump pump
All other visible
Main shut-off valve
Satisfactory
Unsatisfactory
N/A
Load
Main
Main
Main
Main
Main
Amperage
Sub
Sub
Sub
Sub
Sub
Type
Circuit Breaker
Circuit Breaker
Circuit Breaker
Circuit Breaker
Circuit Breaker
Age
Fuse
Fuse
Fuse
Fuse
Fuse
Original
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Satisfactory
Unsatisfactory
Roof Covering:
(mark all that apply)
3-Tab Shingle
Architectural Shingle
Rolled Roofing
Built-up (Tar & Gravel)
Rubber Membrane
Foam
Thermoplastic
Metal Panels
Metal Shingles
Concrete Tile
Clay Tile
Wood Shake
Wood Shingle
Slate
Other ______________
Other Damage Due to:
Overhanging Trees
Algae
Fungus
Product Installation
Manufacturing Defect:
Closed Blistering
Open Blistering
Accelerated Granule Loss
Color Fade
________________________
Telephone Number
________________________
License Type
_________________
License Number
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______________________
Inspection Date