ࡱ> #` Abjbj 4>))))x*qMh,.,.,.,., - - -LLLLLLL$NhAQM/ - -//M.,.,+M000/8.,.,L0/L00CXE., , p4')/(E(F\AM0qM0EpQ/QPEE8QE -hu-J0-<- - - -MM0 - - -qM////&$& Apartment Insurance Questionnaire Please Complete One Questionnaire per Building; Thank You! Applicant Information ( ) Individual), ( ) Corp, ( ) Partnership Email Address:___________ Your Name & dba If AnyMailing Address  FEIN / CA Tax ID / Phone / / ( ) Prior Coverage: Insurance Co. Policy Number: ________ Expiration Date_________ How Long Have You Owned This Property? ___________years Claims Experience: Please Describe All Claims for the last 5 years: ________________________________________________________________________________________________ Physical Location/Address: ____________________________________________ Type of Construction( Frame/Stucco, ( Masonry ( Other (describe):Improvements: Year When UpdatedPlease Provide Year Built and # of Buildings / Units  /Year Wiring Updated Building Square Footage Garages:  (Attached (Detached Sq Ft: _____ Year Plumbing Update Building Insurable Value $ Year Heating Updated Contents Insurable Value (total rent ready per bldg)$Year Roof Updated Annual Rental Income$Subterranean Parking? If Yes, square feet:(Yes ( No Additional Information to Maximize Premium Savings & Coverage Upgrade Pets Allowed? If yes, please describe breeds: (Yes ( NoType of Roof( Shake, ( Tile, ( Comp ( Other (describe): Owned Apartment for ____ YearsAge of Roof: Number of Stories( 1, ( 2, ( 3Flooring Material( Wood, ( Carpet, ( LinoleumFoundation: ( Slab ( RaisedPool / Jacuzzi(Yes ( No; Fenced:(Yes ( NoNumber of FireplacesPlumbing Type( Copper, ( Galvanized, ( PVCCentral Air(Yes ( NoType of Wiring( Conduit, ( FusesType of Heating(Gas __ ElectricHeat Controls(Central, ( Floor, ( Wall Building Sprinklered?( Yes ( NoWeekly Rentals?Weekly Rentals Ineligible  Please Check All that Apply to Your Property: ( Playgrounds, ( Tennis Courts, ( Volleyball Courts, ( Fitness Facilities, ( Recreational facilities ___ Please send me the Insiders Information on Tenant Discrimination, Harassment, & Wrongful Eviction Insurance Protection! No Property Owner should be without it ! APARTMENT OWNERS WORKERS COMPENSATION INFORMATION Locations #STREET, CITY, COUNTY, STATE, ZIP CODE12 Rating Information # EMPLOYEESSTATELOC # (above)CLASS CODE CATEGORIES, DUTIES, CLASSIFICATIONFULL TIMEPART TIMEANNUAL PAYROLL General Information Explain all Yes responses in the Remarks space provided below. ( Yes ( No1. Do you perform any work underground or above 15 feet? ( Yes ( No4. Are sub-contractors used? If yes, give % of and type of work subcontracted:( Yes ( No5. Any work sublet without certificates of insurance?( Yes ( No6. Is a written safety program written and in operation, in compliance with SB198? Other programs?( Yes ( No8. Are there any employees under 16 or over 60 years of age?( Yes ( No9. Are there any seasonal employees?( Yes ( No11. Are there any employees with physical handicaps?( Yes ( No12. Do you require physicals after offers of employment are made?( Yes ( No13. Do you have a written Modified or Return to Work Program for employees returning after an injury? ( Yes ( No14. Do you offer any employee health plans? If so, what percentage of employees participate? %( Yes ( No15. Are employee health plans ( ) paid by the employer or ( ) do employees participate in the cost?( Yes ( No16. Company Benefits include: ( ) Vacation Leave? ( )Sick Leave? ( )Paid Time Off? ( Yes ( No17. Do any employees predominantly work at home?( Yes ( No22. Do you provide transportation for employees?( Yes ( No23. Do you provide vehicles for employees?( Yes ( No24. Do any of your employees drive your or their own vehicles as a part of their work?( Yes ( No25. Do you check driving records for those employees driving on your behalf?( Yes ( No26. Do any employees travel out of state?( Yes ( No30. Has your Workers Compensation Insurance been canceled for non-report of payroll?( Yes ( No31. Is your current insurance company requesting to be replaced?( Yes ( No32. Has your Workers Compensation Insurance been permitted to lapse for over 90 days?( Yes ( No33. Do you have a full-time Human Resources manager? ( Yes ( No34. Are the Owners active in the business?Please provide the following data for the past 5 years of Workers Comp Insurance Policies: Current Insurance Company Expiration Date # of Years Insured w/ Current Insurance Company Policy # Other Assistance for a Final Quote: Current 3-Years claims history Copy of your current declarations page Copy of the most recent audit, if available 3 Easy Ways to Get a Quote for Apartment Insurance: 1. Call: 800-400-3224 or 562-594-6541, extension 21 (Karen) 2. Fax This Questionnaire to 562-594-0376 3. Email This information to  HYPERLINK "mailto:Karen@hdinsure.com" Karen@hdinsure.com Huggins/Dreckman Insurance Agency, Inc. 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