SUPPLEMENTAL APPLICATION
VACANT LAND / REAL ESTATE DEVELOPMENT
1. Applicant2. Property address
3. Legal Description and Zone
4. What are the plans for the land and in what time frame? Is it or ever has it been leased?
5. Acreage?
6. Frontage?
7. Intended use of the land?
8. Previous use of the land? Are there any abandoned projects?
9. Is the land fenced?
10. Are there any posted signs?
11. Describe any water on the land (ponds, flood basin, ditches, streams, pools, or wells).
12. Are there any landfills, mines, quarries, or tanks either on or under the land?
13. Any recreation use of land or leasing of land? (Hunting, Biking, Motorcycles, Fishing, Equestrian, trails, etc.)? If yes, describe:
14. Any farming operations or grazing of animals?
15. Any buildings, other structures, equipment, vehicles or other apparatus on land?
16. Has the land been graded or cleared or are there any plans to do so?
17. Any utilities, streets or roads, utilities or any other infrastructure or development? If no, any planned?
18. Is the land currently for sale or being prepared for real estate development?
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Signature of Applicant Date
The purpose of the Supplemental Questionnaire is to assist in the underwriting process. Information contained herein is specifically relied upon in determination of insurability. The undersigned, therefore warrants that the information contained herein is true and accurate to the best of his knowledge, information and belief. The Supplemental Questionnaire and the application, to which it is appended, shall be the basis of any insurance
______333 Texas Street, Suite 725, Shreveport, Louisiana 71101
(318) 227-3636 * (318) 934-1874 FAX
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