Non-Owner Occupied Survey
Insured 's Name:
Policy #:Trampoline?YesNo
Phone:Swing Set?YesNo
Email Address:Livestock (horses, cattle, etc.)?YesNo
911 Address(Physical Address of Property):Livestock Type:
Street:Livestock Number:
Person Interviewed:Number Dogs:
Year Dwelling was Built:Breed (also needed if mixed)
Year PurchasedAge of Dogs?
Number of Apartments:Dog Temperament?
Number of Occupants:Dogs Bite History?YesNo
Any Smokers in the Home?YesNoIf yes, please explain:
If yes:CigarettesCigarsPipes
Any working smoke detectors in the home?YesNoOther pets?
If Yes:How many?Pelletstove?YesNo
Any working fire extinguishers?YesNoWoodfurnace?YesNo
If Yes:  How many?Woodboiler?YesNo
Any working carbon monoxide detectors?YesNoFrequency of Use:
Age of Central Heating System:
If yes: How many?Heat Type:
BatteryHardwiredFuel Storage Tank?YesNo
Is building managed?YesNoIf yes:Fuel Tank Size:
If yes, by whom:Fuel Tank Type:
Do you or any of your relatives occupy any of the apartments?YesNoFuel Tank Location:
Fuel Tank IngroundYesNo
If yes, how are they related?Fuel Tank Condition
What are tenants occupations and names of employers?Do any of the units have space heaters?YesNo
Is there a lease?YesNoDecks?YesNo
Are Tenants required to carry renters insurance:YesNoIf yes:Height:
Are any of the units currently vacant?YesNoType of Materials:
If yes: How long have they been vacant?GoodExcellent
Is any work needed before they will be ready for occupancy?YesNoAre there any other structures on premises?YesNo
If yes, what are they used for:
Any Business on the premises?YesNo
If yes, please explain:
What arrangement is there for snow and ice removal?
Any Student Housing?YesNo
Electrical Service:Size of Electrical Entrance? (Amps)
DateBy Whom (Insured, Contractor, NA)
Electrical Updated?
Plumbing Updated?
Heating Updated?
Roof Updated?
Additional Survey Comments/Questions:
"Any peson who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
As part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living.  A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal, or extension othe insurance to which this application is made.  The applicant, upon written request, will be informed whetheror not a consumer report was requested - and if such was requested, informed of the name and address of the consumer reporting agency that furnished the report.  The person completing this survey hereby affirms that the statements and representations made herein ae true to the best of his/her knowledge.