UNITED STATES LIABILITY INSURANCE GROUP

A BERKSHIRE HATHAWAY COMPANY Vacant, Partially Vacant, and Building Under Renovations Building Inspection Report
Named Insured: Form of Business: Interviewed/Title: Surveyed by: Survey Date: Mailing Address: Location Information Loc # Street Address City State Zip Code Square Feet Year Built Construction Protection Class # of Stories Policy Number: Corporation Partnership Individual Other:

General Information 1. Is the building completely vacant? (If no complete the General and Partially Vacant section of this form) 2. 3. What is the intended disposition? Date __________ __________ 4. 5. 6. 7. 8. 9. Type/Description: ____________________________________ ____________________________________ Sell Find Lessee Occupy Demolish Other: Any losses in past three years? If yes give complete description: Paid $ $_________ $_________ Reserved $ $_________ $_________

Yes Yes

No No

Open/Closed

________________ ________________ R* A Does the insured own the building (or is insured a tenant with contractual requirement to insure the building)? No Yes Is the building located on a farm? Is the building located on 250 or more acres? Is the building currently damaged – fire, wind or otherwise? Is the building locked, boarded up, or secured (if partially vacant, applies to vacant portion) Any signs of unauthorized entry into the building? Yes Yes Yes No Yes Yes Yes No Yes No No No Yes No No No Yes No

10. Are any renovations, development plans or other construction activities being performed during our policy term? (if yes, complete the Building Under Renovation section of this form) 11. Any tenant evicted within the past 60 days? 12. Is the insured actively engaged in trying to sell/lease the building? 13. Is the building obsolete with no further potential? 14. How long has the building been vacant? 15. Any financial difficulties learned as a result of the vacancy? 16. How often are checks made on the premises? Partially Vacant N/A 17. Describe tenants: 18. Does the building have aluminum or knob & tube wiring? 19. Is all electric on functional circuit breakers? 20. Are there functioning and operational smoke/heat detectors in those units, common areas and mechanical areas, which you physically have inspected? Vacant & Partially Vacant Building and Building Under Renovation Inspection Report Form 2-08-08 edition By whom?

Yes No No

No Yes Yes

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21. Is there a valid certificate of occupancy for each tenant? Property Information 22. Are there any adjacent exposures? (If yes answer 22a.) 22a. Are any of the adjacent exposures vacant and NOT locked, boarded up, or secured from unauthorized entry? 23. Is the building in an area prone to floods, tornados or brush fires? 24. Is there a sprinkler system? (If yes answer 24a thru 24c) 24a.Are functioning and operational sprinklers covering 100% of building? 24b. Is heat maintained at a level throughout the building to prevent pipes from freezing? 24c. If heat is not maintained, is system drained and shut off? 25. Any accumulation of debris? 26. Is this a mobile home? Property Special Cause of Loss 27. Is plumbing completely PVC or Copper? 28. Is all electric connected to functional circuit breakers? 29. Roof construction: 30. Roof age (if flat, indicate date last recoated): Building Under Renovation N/A 31. Cost of Renovation or Rehab: 32. Who is performing the renovations? 34. Are any structural renovations planned? 35. Do the renovations include any additions to the building? 36. Do the premises contain any underground storage tanks? 37. Does the project involve any of the following: bridges; dams; tunnels; bubble buildings; green houses; waste water treatment facilities; airport hangers; silos; chemical, energy co-generation or petroleum facilities; radio, television or communication towers? 38. Are any demolition or blasting operations planned? * Provide details on any responses in the “R” column: None Applicant Contractor Other: 33. How many years of experience does the applicant/contractor have in conducting renovation projects?

No Yes No Yes Yes Yes No No Yes Yes

Yes No Yes No No No Yes Yes No No

No No

Yes Yes

Yes Yes Yes

No No No

Yes Yes

No No

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Vacant & Partially Vacant Building and Building Under Renovation Inspection Report Form 2-08-08 edition

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Specific Underwriting Questions:

_________________________________________________________________________________________ _ _________________________________________________________________________________________ _________________________________________________________________________________________ __Recommendations/Comments:
No Yes (if yes list below)

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Vacant & Partially Vacant Building and Building Under Renovation Inspection Report Form 2-08-08 edition

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