Vacant Building Questionnaire Agent/Agency's Name(Required)Select Your AgentAllen Miracle - 325Ann Kwasnick Hacker - 274Barb Schimmel - 203Bollinger, Inc. - 369Christopher W. Fitts - 215ChurchWest Insurance Services - 100Connie Butler - 342Countybanc Insurance, Inc. - 379David Takagi - 216Dena L. Johnson - 338Donald Hamm - 292Douglas Dischinger - 295Evan Mandigo - 362Gabe Michaels - 260James Stewart - 213Jas. D. Collier & Co. - 334Jas. D. Collier & Co. - 380Jeff Carpenter - 333Jeff McDonnell - 270Jensen Ford Insurance Agency - 368Jeremy Butler - 289Jim Garner - 356Jim Jensen – 218Jo Ann Litwin - 212John Bouhall - 267John Schultz - 237Josh Larson - 228Julius Anderson - 340Kevin Dotseth - 348Kurt Hetherington - 385Linda Senez - 366Matthew Huntington CLU, LUTCF - 336Michael A. Krause, CIC - 236Michele Dolliff, AAI, CLCS - 249Miller Agency – 250Patricia Stein - 327Phil Collins - 335Pmm Services, Inc. - 253RH Sims Insurance Agency - 384Richey-Barrett Co. – 298Sharon Thompson - 202Shawn Polzin - 357Sovereign Insurance Group - 230Sovereign Insurance Group - 238Sovereign Insurance Group - 280Sovereign Insurance Group - 294Sovereign Insurance Group - 378Strong Tower Insurance, Inc. - 339Strong Tower Insurance, Inc. - 383United Church Ins. Svcs. - 365United Church Ins. Svcs. - 998United Church Ins. Svcs. - 999William A Smith and Son, Inc - 347Worgess Agency, Inc DBA Worgess Insurance & Financial Services - 377Your Name(Required) First Last Your Email Address(Required) Enter only one valid email address. A copy of the submission will be sent to this email address.Participant/Church IB #(Required)Current participants only. Use New Business form or email for prospects. Please enter IB# as shown on the MOI without "PK" policy #.Participant/Church Name(Required)As shown on the MOI.Participant/Church City(Required)State(Required)Select a StateALAKAZARCACOCTDEDCFLGAHIIAIDILINKSKYLAMEMDMAMIMNMOMSMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVAVTWAWIWVWYParticipant Zip Code(Required)Name/Description of vacant building(Required)Location/Address of Vacant Building(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date building became or will become vacant(Required) MM slash DD slash YYYY What percentage of the building is/will be vacant(Required) 100% 31% or more; less than 100% Less than 31%Why has/will the building become vacant?(Required)What is the intended disposition?(Required) Sell Find Lessee Occupy Demolish OtherWhen do you expect the disposition to occur?(Required)Was the property for sale or purchased in the last three years?(Required) Yes NoWhat is/was the sale price?Is regular maintenance performed?(Required) Yes No Other(Roof leaks, gutters, windows, steps, railings, etc.)Do you maintain an occupied appearance to the property?(Required) Yes No Other(Mow lawn, mail forwarded, snow shoveled, windows cleaned, light timers, etc.)How will the vacant building be secured? (select all that apply)(Required) Locked Alarmed Boarded Patrolled Daily security checks Weekly security checks Monthly security checks Notified local authorities to watch for criminal behavior Other NoneOther security on vacant building(Required)Are there functioning and operational alarms/detectors in the vacant building?Fire/Smoke Alarm(Required) Yes & Centrally Monitored Yes & Local Siren Only Yes but less than half the building NoBurglar/Intrusion Alarm(Required) Yes & Centrally Monitored Yes & Local Siren Only Yes but less than half the building NoSecurity Camera(s)(Required) Yes & Centrally Monitored Yes & Local Siren Only Yes but less than half the building NoWater Leak Detection(Required) Yes & Centrally Monitored Yes & Local Siren Only Yes but less than half the building NoIf sprinklered, is the sprinkler activated and regularly tested?(Required) Yes No & drained No & not drained No sprinkler OtherStatus of UtilitiesWater(Required) On Off Will Be Turned Off N/AElectric(Required) On Off Will Be Turned Off N/AGas(Required) On Off Will Be Turned Off N/AHeat (maintained at 55° or higher)(Required) On Off Will Be Turned Off N/AIf water is off, has the plumbing system been completely drained?(Required) Yes No N/A Water is on OtherAre there any appurtenant structures such as a garage, shed, playground, etc.?(Required) Yes NoIf yes, please explain:(Required)Are there any prior losses while vacant or in the last 3 years?(Required) Yes NoIf yes, please explain:(Required)Is the property currently damaged (by fire or otherwise)?(Required) Yes NoIf yes, please explain:(Required)Is the building undergoing construction or renovation?(Required) Yes NoIf yes, please explain:(Required)Is the building obsolete or without any further potential use?(Required) Yes NoIf yes, please explain:(Required)Do any of the following apply to the vacant building?(Required) Combustible, chemical, pollutant or any type of environmental hazard on the premises Underground and/or above ground fuel/oil tanks Farming Campground activities and/or swimming pool Trailer or mobile home Knob and tube wiring Condemned or government order to vacate or demolish Foreclosure, receivership, tax liens or bankruptcy N/A; none applyPlease upload current exterior and interior photos(Required) Drop files here or Select filesMax. file size: 50 MB.Rush Request?(Required) Yes NoIf less than 30 business days, requests will be treated as rushes ONLY IF a reason for the rush is described below and a need by date is provided.Additional Comments or Instructions:
