Application Questionnaire

Basic Information About Your Business

First Name:		Last Name:
Address:
City:		State:	select... Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code:
Phone:		Fax:
Applicant Is:	Individual  Partnership  Corporation  LLC  Trust  Other
Effective Date:			Expiration Date:
Present Carrier:			Premium Paid:
Number of Self-Storage Facilities Owned/Managed:
Member of Storage Owners Association?		Yes No
Attend Industry Loss Prevention Seminars?		Yes No
Name of Association:
Number of Years in the Storage Industry:
Name and Address of Storage Facility:
County:		Protection Class:
Mortgagee Name and Address:
Loan Number:
Named Insured (if different from applicant) and Mailing Address:	Owner  General Lessee  Property Management Co.
Additional Insured Name, Address, and Interest:

Your Business Property

Coverage	Limits of Liability
A. Business Property - Buildings (Replacement Basis)
B. Business Personal Property (Replacement Basis)
C. Deductible   $1,000  $2,500  $5,000  $10,000

Description of Storage Facility

Number of Self-Storage Buildings		Number of Non Self-Storage Buildings
Year Constructed		Distance Between Buildings
Total Area (Gross Square Feet)		Number of Stories
Construction Material		Exterior Walls
Joisting		Interior Partitions
Roof		If Metal, State Gauge Thickness
Wind Updrift Classification:	Ordinary  Semi-Wind Resistive  Wind Resistive
Climate-Controlled Storage?	Yes  No	Operational Fire Sprinkler System?	Yes  No

Premises Protection

Is Rental Office on Site? Yes No  If No, Provide Complete Address Below: Does lease agreement contain verbiage which specifically prohibits the storage of hazardous materials, toxic waste, and other pollutants? Yes No  Designed Originally for Self-Storage? Yes No  If No, Purpose Designed For: Was A Licensed Contractor Used? Yes No  Has Property Suffered Flood or Surface Water Accumulation? Yes No  If Yes, Explain How: If Coastal Area, Distance From Beach: Is Facility Inside City Limits? Yes No  Name of Servicing Fire Department: Distance to Fire Department: Distance to Nearest Fire Hydrant: Fire Alarms Installed? Yes No  Connected to Central Station? Yes No  Burgler Alarms Installed? Yes No  Connected to Central Station? Yes No  Gates Visible From Manager's Office? Yes No  Do You Have A Driveway Bell? Yes No  Do You Have TV Surveillance? Yes No

Positive ID Required When Lease Is Signed? Yes No  Does Manager Reside On Premises? Yes No  Does Manager Check Tenants Locks on a Daily Basis? Yes No  Local Police Patrol? Yes No  Private Patrol? Yes No  Armed Security Guard? Yes No  Guard Dogs? Yes No  Dog Warning Signs Posted? Yes No  Where Are Dogs Kept During Business Hours? Premises Fully Lighted At Night? Yes No  Manual 'Sign In/Sign Out' System? Yes No  Complex Fully Fenced or Enclosed? Yes No  Fence Type and Height: Number Of Entries: Number Of Exits: Gate Access & Control System Locked Manually? Yes No  Automated Barrier Arm? Yes No  Keyboard Touchpad? Yes No  Card Entry? Yes No  Sliding Gate? Yes No

Non-Storage Activities

Are Any Tenants Conducting Manufacturing, Repair Work, Retail, or any other non-storage operations? Yes No	Does the Named Insured have any business activities other than Self-Storage operations occurring on the premises? Yes No
If Yes, describe, including the building in which they are located:	If Yes, describe, including the building in which they are located:

Supplemental Operations Information

Does the Owner also act as the Manager?	Yes No	Are duplicate keys to rented storage units retained by the facility?	Yes No
Employees/Management Number of Years Experience in Self-Storage Industry:		If Yes, Who Retains Keys?
Forklifts or Loaders Used?	Yes No	Who Has Access To Keys?
Elevators or Lifts Used?	Yes No	Where Are The Keys Kept?
Are Padlocks Sold At The Rental Office?	Yes No	Annual Rental Income:
Number of Rental Spaces in Buildings?		Number of Open Lot Spaces (Boats, RV's, etc.)?
Is there now, or has there ever been, problem(s) and/or claim(s) relating to mold or mildew on the premises? Yes No

Supplemental Sale & Disposal Legal Liability Information

What State Law Code Section is followed when reclaiming spaces?
What limitations are placed on a Manager's authority?
How many sales of individual tenants' property occurred within the last twelve (12) months?
What was the total amount recovered from such sales?
List the number of days after initial rental delinquency that tenant's property may be sold:

Loss History

Enter all claims or occurrences that may give rise to claims for the prior 5 years.		Check Here If None
Date of Occurrence	Description of Occurrence or Claim	Amount Paid