Vacant Home Supplemental Questionnaire

APPLICANT’S INFORMATION

Applicant’s Name:___________________________________________________________

How often is the home visited? ____________________________________

If the owner of the home is out of state and/or more than 100 miles away who maintains the
property and makes regular visits?
_____________________________________________________________

During the regular visits to the home is the interior and exterior inspected?
(Please circle one) Yes No

Please note: Underwriting guidelines require the home to be inspected for signs of forcible entry and interior
distress every two weeks.

Why is the home vacant? ________________________________________

How long has the home been vacant? ______________________________

Are the utilities (heat/lights/water, etc) active in the home? Yes No

By evidence of my signature, I swear that all of the answers to the above questions and the information provided are correct and
accurate representations. I further understand that placement of coverage is contingent on the accuracy of these representations. I
understand that the Company and its representatives have the right to inspect the inside and outside of the premises to verify the
information provided and give my consent to such inspection.

Signature of Applicant: _______________________________Date:___________

Policy Number: __________________________

HOME OFFICE: CHARLESTON, SC

OTHER LOCAT IONS: MONTGOMERY, AL  ATLANT A, GA  COLUMBUS, GA  CHARLOTTE, NC
RALEIGH, NC  PHILADELPHIA, PA  WESTMINSTER, SC  NASHVILLE, TN  RICHMOND, VA
PHONE (843) 577-0800  800-487-7565  WWW.JJINS.COM
P.O. BOX 899  CHARLESTON, SC 29402