2010 Uniform Mitigation Verification Inspection Form printable pdf download

Uniform Mitigation Verification Inspection Form

Maintain a copy of this form with the insurance policy

Inspection Date:

Owner Information

Owner Name:

Contact Person:

Address:

Home Phone:

City:

Zip:

Work Phone:

County:

Cell Phone:

Insurance Company:

Policy #:

Year of Home:

# of Stories:

Email:

NOTE: At least one photo documenting the existence of each visible and accessible construction or mitigation attribute

must accompany this form.

Your insurer may ask additional questions regarding your mitigated feature(s).

Comment [jf1]: Moved photo requirement and

insurer statement to the top of the form.

1. Building Code: What building code was used to design and build the structure?

Comment [jf2]: Citizens recommends to retain

the current building code wording with the current

A. 1994 South Florida Building Code (building permit application date of 9/1/1994 or later in Miami-Dade and Broward

building code classifications.

Counties (also known as the High Velocity Hurricane Zone (HVHZ)).

B. Building code prior to the 1994 South Florida Building Code (building permit application date of 8/31/1994 or earlier in

Miami-Dade and Broward Counties (HVHZ).

C. 2001 Florida Building Code (building permit application date of 3/1/2002 or later outside the HVHZ).

D. Building code prior to the 2001 Florida Building Code (building permit application date of 2/28/2002 or earlier outside

the HVHZ).

E. Unknown or undetermined.

2. Roof Covering(s): (All roof coverings must be in good condition, able to perform/function as intended, and meet the FBC or

SFBC requirements listed below)

Comment [jf3]: Citizens recommends the

removal of the word Predominant as all roof

Condition

Good

Poor

coverings should be compliant and able to function

Permit Application Date: _________ (mm/yyyy) or Date of Installation: ____________(mm/yyyy)

as intended or the credit should not apply.

For fiberglass/asphalt shingles, at a minimum meets the Florida Building Code or the 1994 South Florida Building Code

and has a Miami-Dade NOA or FBC Product Approval listing demonstrating compliance with ASTM D 3161 (enhanced for

110MPH) Class F OR ASTM D 7158 (Class F, G or H), OR FBC TAS 100-95 and TAS 107-95.

B. For clay or concrete tile roof coverings, wood shake roofs, rolled roofing, or built up roofing; has a Miami-Dade NOA or

FBC Product Approval listing that is/was current at the time of installation.

C. For Metal roof coverings, has a Miami-Dade NOA or FBC Product Approval listing that is/was current at the time of

installation.

D. One or more covering does not meet the above minimum requirements.

E. No roof covering meets the above minimum requirements.

F. Unknown or undetermined.

Comment [jf4]: No change to this section.

3. Roof Deck Attachment: What is the weakest form of roof deck attachment?

A. Plywood/Oriented strand board (OSB) roof sheathing attached to the roof truss/rafter (spaced a maximum of 24” o.c.) by

staples or 6d nails spaced at 6” along the edge and 12” in the field. -OR- Batten decking supporting wood shakes or wood

shingles.-OR- Any system of screws, nails, adhesives, other deck fastening system or truss/rafter spacing that has an

equivalent mean uplift resistance of 55 psf.

B. Plywood/OSB roof sheathing with a minimum thickness of 7/16” attached to the roof truss/rafter (spaced a maximum of

24” o.c.) by 8d common nails spaced 6” along the edge and 12” in the field.-OR- Any system of screws, nails, adhesives,

other deck fastening system or truss/rafter spacing that has an equivalent mean uplift resistance of 103 psf.

Inspectors Initials _____ Property Address_____________________________________________________________

*This verification form is valid for five (5) years provided no material changes have been made to the structure. An insurer at

its expense may require that this form be independently verified before accepting the form as valid.

Page 1 of 4

OIR-B1-1802 (Rev. 02/10) Adopted by Rule 69O-170.0155

2010 Uniform Mitigation Verification Inspection Form

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