WIND
			COVERAGE
Named Insured
Mailing Address
City
State
Zip Code
Location #1 Name
Address
City
State
Zip Code
Construction		Please select one Fire Resistive Joisted Masonry Light Metal Frame Masonry Non-Combustible Modified Fire Resistive Non-Combustible Wood Frame
Tenancy		Please select one Owner Occupied Tenant Occupied Vacant
Primary Occupancy
Secondary Occupancy
Number of Stories
Total Square Footage
Year Constructed (YYYY)
Roof Shape		Please select one Hip Roof Flat Roof Gable Roof
Roof Cladding		Please select one Wood, Shake OR Shingles Asphalt Shingles Tile or Clay Steel or Metal Built Up
Roof Age (YYYY)
Fire Protection		Please select one Poor Standard Good Superior
Protection Class		Please select one pc-1 pc-2 pc-3 pc-4 pc-5 pc-6 pc-7 pc-8 pc-9 pc-10
Exterior Cladding		Please select one Exterior Insulated Finishing System Other Wood Exterior Cladding
Security		Please select one Poor Standard Superior
Wind Resistive		Please select one Yes No
Does this building have aluminum wiring		Please select one Yes No
Is this Government Subsidized Housing		Please select one Yes No
Is the Occupant of this Building a non-profit organization		Please select one Yes No
Building Coverage Amount
Business Personal Property Amount (including Tenants Improvements & Betterments)
Agency Name:
Agency Address:
Agency Phone:
Agency Fax:
Agency Contact:
Contact E-Mail Address: