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Environmental Health & Safety
Building Insurance Request
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Building Name: Building Number: Funding Source: Select Education and General Contracts and Grants Auxiliary
Street Address: City: State: AK AL AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: County:
Is the building within city limits? No Yes
Does the building have a basement? No Yes
Stories (excluding basement): Square Footage: Most recent construction year: Occupancy: Select Educational Office Penal Recreational Residential Storage Other
Other Occupancy Type:
Sprinklered (%):
Exterior Wall: Select Frame Masonry Semi Wind Resistive Wind Resistive Other
Exterior Wall Subtype: Select Aluminum Frame Frame with Masonry Heavy Timber Frame with Metal Covering Laminated Wood Frame Plywood on Glue Stucco Veneer
Exterior Wall Subtype: Select Brick Concrete Block Masonry, hollow Masonry, hollow with Brick Veneer Masonry, NC
Exterior Wall Subtype: Select Fire Resistive / Heavy NC Pre-Engineered Metal Towers, Communication / Water
Exterior Wall Subtype: Select Poured Concrete Pre-Cast Concrete Tilt-Up Concrete
Other Wall Subtype
Roof Support: Select Frame Masonry Semi Wind Resistive Wind Resistive Other
Roof Support Subtype: Select Boards on Joist Frame Frame with Metal Covering-Trillers or Sheds Heavy Timber Plank on Exposed Steel Plank on Timber Wood Joist Plywood on Glue Laminate/Wood Frame Plywood on Laminate Beam Wood Truss on Steel
Roof Support Subtype: Select Masonry Joist Masonry NC
Roof Support Subtype: Select Fire Resistive / Heavy NC Protected Steel Steel Deck and Other Light NC Steel Deck / Combustible
Roof Support Subtype: Select Air Supported Poured Concrete Pre-Cast Concrete Pre-Engineered Metal
Other Roof Support Subtype
Is the Building: Select Owned Leased
Building Replacement Cost:
Building Value:
Contents (actual value): Flood Zone: Select A V X Unknown Is building owned by any Agency, Board or Bureau of the State of Florida? Select No Yes Distance to Ocean/Gulf: Select <=1 Mile >1 Mile, <=5 Miles >5 Miles, <=10 Miles >10 Miles, <=50 Miles >50 Miles, <=100 Miles >100 Miles Fire Department Name: Nearest Hydrant (estimate in feet): Fire Pump: Select No Yes
Select Yes No Keypad/Keycard Entry Select Yes No Cameras Select Yes No Building Lock Down Select Yes No Police Drive-by Select Yes No Entry Security Station Select Yes No Watchman
Select Yes No Protected Signaling System
Select Yes No Alarm Services
Other Alarm Services Type:
Select Yes No Alarm Systems Select Auxiliary Carbon Dioxide Central Station Closed Circuit Dry Chemical Foam Extinguishing Halon Local Proprietary Remote Station Water-Mist Select Yes No Water Supply Select City and Private Supply City Supply City with Booster Pump Combined Domestic Fire Protection Supply Fire Pump and Tank or Equivalent Supply Nearly Reliable Public Water Supply or Equivalent Private-Combined Gravity/Pumping Private-Gravity Pump Private-Pumping Supply Reliable Public Water Supply or Equivalent Two Independent and Fully Adequate Supplies Unreliable Fire Pump and Tank or Equivalent Unreliable Public Supply
Select Auxiliary Carbon Dioxide Central Station Closed Circuit Dry Chemical Foam Extinguishing Halon Local Proprietary Remote Station Water-Mist
Select Yes No Water Supply
Select City and Private Supply City Supply City with Booster Pump Combined Domestic Fire Protection Supply Fire Pump and Tank or Equivalent Supply Nearly Reliable Public Water Supply or Equivalent Private-Combined Gravity/Pumping Private-Gravity Pump Private-Pumping Supply Reliable Public Water Supply or Equivalent Two Independent and Fully Adequate Supplies Unreliable Fire Pump and Tank or Equivalent Unreliable Public Supply
Manufacturer: KW: Gal: Fuel:
Select Yes No Boiler
Manufacturer: Type: BTUs: Location (e.g. kitchen, equipment room, etc.):
Name: Title: Phone: Email:
