UNITED STATES LIABILITY INSURANCE GROUP

A BERKSHIRE HATHAWAY COMPANY

Vacant, Partially Vacant, and Building Under Renovations Building Inspection Report

Named Insured: Policy Number:

Form of Business: Corporation Partnership Individual Other:
Interviewed/Title:
Surveyed by: Survey Date:
Mailing Address:
Location Information
Loc Zip Square Year Protection # of
Street Address City State Construction
# Code Feet Built Class Stories

General Information
1. Is the building completely vacant? (If no complete the General and Partially Vacant section of this form) Yes No
2. What is the intended disposition? Sell Find Lessee Occupy Demolish Other:
3. Any losses in past three years? If yes give complete description: Yes No
Date Type/Description: Paid Reserved Open/Closed
$ $
__________ ____________________________________ $_________ $_________ ________________
__________ ____________________________________ $_________ $_________ ________________
R* A
4. Does the insured own the building (or is insured a tenant with contractual requirement to insure the building)? No Yes
5. Is the building located on a farm? Yes No
6. Is the building located on 250 or more acres? Yes No
7. Is the building currently damaged – fire, wind or otherwise? Yes No
8. Is the building locked, boarded up, or secured (if partially vacant, applies to vacant portion) No Yes
9. Any signs of unauthorized entry into the building? Yes No
10. Are any renovations, development plans or other construction activities being performed during our policy term? Yes No
(if yes, complete the Building Under Renovation section of this form)
11. Any tenant evicted within the past 60 days? Yes No
12. Is the insured actively engaged in trying to sell/lease the building? No Yes
13. Is the building obsolete with no further potential? Yes No
14. How long has the building been vacant?
15. Any financial difficulties learned as a result of the vacancy?
16. How often are checks made on the premises? By whom?

Partially Vacant N/A

17. Describe tenants:
18. Does the building have aluminum or knob & tube wiring? Yes No
19. Is all electric on functional circuit breakers? No Yes
20. Are there functioning and operational smoke/heat detectors in those units, common areas and mechanical areas,
which you physically have inspected? No Yes

Vacant & Partially Vacant Building and Building Under Renovation Inspection Report Form 2-08-08 edition Page 1 of 3
21. Is there a valid certificate of occupancy for each tenant? No Yes

Property Information
22. Are there any adjacent exposures? (If yes answer 22a.) Yes No
22a. Are any of the adjacent exposures vacant and NOT locked, boarded up, or secured from unauthorized entry? No Yes
23. Is the building in an area prone to floods, tornados or brush fires? Yes No
24. Is there a sprinkler system? (If yes answer 24a thru 24c) Yes No
24a.Are functioning and operational sprinklers covering 100% of building? Yes No
24b. Is heat maintained at a level throughout the building to prevent pipes from freezing? No Yes
24c. If heat is not maintained, is system drained and shut off? No Yes
25. Any accumulation of debris? Yes No
26. Is this a mobile home? Yes No

Property Special Cause of Loss

27. Is plumbing completely PVC or Copper? No Yes
28. Is all electric connected to functional circuit breakers? No Yes
29. Roof construction:
30. Roof age (if flat, indicate date last recoated):

Building Under Renovation N/A

31. Cost of Renovation or Rehab:
32. Who is performing the renovations? Applicant Contractor Other:
33. How many years of experience does the applicant/contractor have in conducting renovation projects?
34. Are any structural renovations planned? Yes No
35. Do the renovations include any additions to the building? Yes No
36. Do the premises contain any underground storage tanks? Yes No
37. Does the project involve any of the following: bridges; dams; tunnels; bubble buildings; green houses; waste
water treatment facilities; airport hangers; silos; chemical, energy co-generation or petroleum facilities; radio,
television or communication towers? Yes No
38. Are any demolition or blasting operations planned? Yes No

* Provide details on any responses in the “R” column: None

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Vacant & Partially Vacant Building and Building Under Renovation Inspection Report Form 2-08-08 edition Page 2 of 3
Specific Underwriting Questions:
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__Recommendations/Comments: No Yes (if yes list below)

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Vacant & Partially Vacant Building and Building Under Renovation Inspection Report Form 2-08-08 edition Page 3 of 3