USI INSURANCE SERVICES

Location Information Application

To Be Completed for Every Location/Building

Insured Name: / Click to enter
Location #: / Click to enter
1. / Location of Building (Complete Street Address): / Click to enter
City: / Click to enter / State: / Click to enter / Zip: / Click to enter
2. / Building Occupied As: / Click to enter
List Other Occupancies of this Building: / Click to enter
3. / Is Building / Owned: / / (If Owned) Mortgagee: / Click to enter
Leased: / (Include Copy) / / Mortgagee Address: / Click to enter
Other: / Use & Occupy: / / Click to enter
Tenant at Will: / / Click to enter
4. / Additional Insured: / Click to enter
Address: / Click to enter
Insurable Interest: / Building: / / Contents: / / Liability: /
Explain Interest: / Click to enter
5. / Building Replacement Value: / $ / Click to enter
6. / Contents Replacement Value: / $ / Click to enter
7. / Replacement Value of Other Property:
a.) / Personal Property of Others: / $ / Click to enter / (includes property of staff, clients, customers, students)
b.) / Improvements and Betterments: / $ / Click to enter / (leased space only)
c.) / Exterior Signs: / $ / Click to enter
d.) / Fences / $ / Click to enter
e.) / Glass: / $ / Click to enter
8. / Year Built / Click to enter
9. / Year Updated: / Plumbing: / Click to enter / Electrical: / Click to enter
Heating: / Click to enter / ROOF
10. / Occupied: / / Vacant: /
If vacant, how long and why? / Click to enter
11. / Number of Stories: / Click to enter / (not including attic or basement)
Attic: / / Basement: /
12. / Total Area of Building: / Click to enter / Square feet
13. / Part you Occupy: / Click to enter / Square feet; / Click to enter / % of total
14. / Building Information:
Construction: /
a) / Sprinklers / / h) / Emergency Lighting /
b) / Smoke Detectors / / i) / Enclosed Stairways /
c) / Heat Detectors / / j) / Exits Unobstructed /
d) / Fire Alarms / / k) / Evacuation Plan
(Include Copy) /
e) / Outside Fire Escape / / l) / Number of Exits / Click to enter #
f) / Intrusion Alarm / / m) / Number of Beds / Click to enter #
g) / Automatic Extinguish System over Stove / Cooking Area
(Ansul System) /
15. / Are the sprinklers serviced: /
16. / Is the Ansul System serviced: /
17. / a) / Describe neighbor to the right and distance:
Click to enter
b) / Describe neighbor to the left and distance: / Click to enter
c) / Describe neighbor to the rear and distance:
Click to enter
18. / Electronic Data Processing Equipment/Computer
a) / Hardware / $ / Click to enter
b) / Software / $ / Click to enter
19. / Boiler and Machinery Coverage / $ / Click to enter / limit (only if building is owned)
Click to select date
Signature / Date Completed
Click to enter
Name & Position

If available, please include a recent photo of all buildings.

Send this completed form to: USI INSURANCE SERVICES

123 Interstate Drive

PO Box 3600

West Springfield, MA 01090-3600

Or, you may fax it to: (413) 733-7722

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