4-Point Insurance Inspection Form Page 2
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1
24-Point Insurance Inspection – #___________
(2014 Edition)
P
S
LUMBING
YSTEM
Overall Plumbing System:
Deficiencies (check all that apply):
Supply
Drain
Age of System: __________
Active leak
Copper
Copper
Type:
Year Last Updated: __________
PVC
CPVC
Indication of prior leak(s)
Galvanized
Galvanized
Plumbing system in good working order? ___
Connections/Hoses leaking
Polybutylene
Cast Iron
or cracked
Estimated 5 Yrs. Remaining: ____
____________
___________
Water Heater: ______________
_____________________________
Hot Water Heater:
_____________________________
Year
Age: __________
______________
Updated:
______________
Other: ____________________
Condition: __________
____________________________
Location: __________
____________________________
Condition:
______________
______________
Use the Additional Comments/Observations Section below to provide full details of all updates, hazards, etc.
R
OOFING SYSTEM
Overall Roofing System:
Roof Covering Material(s):
Year Last Updated: __________
Predominate Covering
Covering #3
Covering #2
If updated:
Full Replacement
______________
______________
______________
Type:
Partial Replacement
______________
______________
______________
Percentage:
% of Replacement ____________
______________
______________
______________
Age:
Overall Condition of Roof: ___________
______________
______________
______________
Remaining Life:
Deficiencies (check all that apply):
______________
______________
______________
Permit Date:
Any visible signs of damage/deterioration?
______________
______________
______________
(e.g. curling/lifted/loose/missing shingles or
Permit #:
tiles, sagging or uneven roof deck)
______________
______________
______________
Condition:
Any signs of visible leaks?
______________
______________
______________
Elastomeric Date:
Use the Additional Comments/Observations Section below to provide full details of all updates, hazards, etc.
A
C
O
:
DDITIONAL
OMMENTS OR
BSERVATIONS
I
I
.
CERTIFY THAT
PERSONALLY INSPECTED THE PREMISES AT THE LOCATION ADDRESS LISTED ABOVE ON THE INSPECTION DATE NOTED
I
.
CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT
________________________________
_____________________________
_____________________________
_____________
I
S
T
L
N
D
NSPECTOR
IGNATURE
ITLE
ICENSE
UMBER
ATE
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