Test New Location Form

Is this location:

Newly completed construction?
Acquisition of an existing structure?

1. Name of Location

Address of Location

Street Address Address Line 2 City State ZIP Code

2. What is the location going to be used for?

Administration
Garage
Maintenance Building
School
Transportation Complex
Other

If your answer to previous question is "Other" please explain:

If a school, please fill in the following:

Grade levels served:	Total number of students:	Average daily attendance:	Latch Key program? (yes or no)

How many employees will work at this location

Full time:	Part time:

3. What is the size (acreage) of the location?

4. Describe the area surrounding the location:

Industrial
Commerical
Residential
Rural

5. Are there any wetland areas or preserves on the location?

6. What is the water supply source for the location?

Municipal Water Well
Municipal Reservoir
City Water Supply
Other

If your answer to previous question is "Other" please describe:

7. Which of the following are included in recreational areas at the location?

Swimming Pools
Athletic Fields
Tracks
Tennis Courts

8. Waste Disposal: Does the location operate or participate in any of the following?

Incinerator
Landfill
None
Other

If your answer to previous question is "Other" please describe:

Who is responsible for solid waste collection? (Explain)

9. Is any portion of the property occupied by the location designated “environmentally contaminated”?

If your answer YES to previous question, please explain:

10. To your knowledge, is any property adjacent to the location designated “environmentally contaminated”?

If your answer YES to previous question, please explain:

11. How many buildings will be at location?

12. BUILDING SPECIFICS (Complete for each building at the location.)

Will building be located in Federal Flood Zone A?

Yes
No

Will building be leased?

Yes
No

If yes, from whom?

If yes, are you responsible for insuring the building?

What is the square footage of the building?

How many floors does it have?

Check this box if it applies to the building’s protections:

Manual Pull Fire Alarm?

Central Station?

Check this box if it applies to the building’s protections:

Sprinkler System?

Central Station?

Check this box if it applies to the building’s protections:

Smoke/Heat Alarm?

Central Station?

Check this box if it applies to the building’s protections:

Burglar/Intruder Alarm?

Central Station?

Check the appropriate construction type:

Wood frame with plywood exterior wall and roof decking.
Wood frame with masonry walls and wood roof decking.
Steel frame with masonry walls and concrete roof deck.
Steel frame with masonry walls and steel roof deck.

Check the appropriate roof covering description:

Asphalt shingles
Carlisle rubber roof or similar product
Poured asphalt with rock
Other

If you answered "Other", please describe:

13. Provide the replacement cost value for each type of property described:

Building:

Property:

Outdoor Property:

Time Element:

Extra Expense:

Business Income:

TOTAL VALUATION SPECIFIC TO THIS BUILDING:

$0.00

NEW LOCATION QUESTIONNAIRE CERTIFICATION:

I have examined the underwriting information herein contained and submitted on behalf of the School District and I certify that this information is complete, true, and accurate to the best of my knowledge. I am aware that omissions or inaccuracies in the material submitted may result in a revised contribution and, in certain extreme cases, a lack of coverage.

District:

Business Official Name and Title:

Name and Title of person completing the form: (if not the Applicant)

Contact Email:

School Pool for Excess Liability Limits

Joint Insurance Fund

Test New Location Form

12. BUILDING SPECIFICS (Complete for each building at the location.)

13. Provide the replacement cost value for each type of property described:

Contents:

Property:

Time Element:

NEW LOCATION QUESTIONNAIRE CERTIFICATION:

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