CIU® 901 E St. Louis St, Ste 205 Phone (417)883-3277 Springfield, MO 65806 Fax (417)883-3393 Watts (800) 241-9759 VACANT BUILDING PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to ACORD Application) Applicant’s Name: Agency Name: Agent No.: Location Address: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE APPLICABLE” (N/A) “NOT 1. Building Information: Loc. No. of Vacant Location Address Construction Age No. Stories 1 2 3 Utilities that are still turned on: Loc. Prior Occupancy Gas Electric Water No. 1 2 3 Area Occupied Loc. Vacant Total Building Current Building Use or Leased To No. Area (sq. ft.) Square Footage Others (sq. ft.) 1 2 3 2. Building Security/Neighborhood: Neighborhood Building Security (“x” those applicable) (“x” those applicable) Loc. Guarded How often do you Boarded Fenced Alarmed No. Locked 24-Hours see the building? 1 2 3
CIU® 901 E St. Louis St, Ste 205 Phone (417)883-3277 Springfield, MO 65806 Fax (417)883-3393 Watts (800) 241-9759 VACANT BUILDING PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to ACORD Application) Applicant’s Name: Location Address: Agency Name: Agent No.: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A) 1. Building Information: Loc. No. Location Address Construction Age No. of Stories Vacant 1 2 3 Utilities that are still turned on: Loc. No. Prior Occupancy Gas Electric Water 1 2 3 Loc. No. Current Building Use Vacant Area (sq. ft.) Area Occupied or Leased To Others (sq. ft.) Total Building Square Footage 1 2 3 2. Building Security/Neighborhood: Building Security (“x” those applicable) Neighborhood (“x” those applicable) Loc. No. Boarded Locked Fenced Guarded 24-Hours Alarmed How often do you see the building? 1 2 3
Vacant%20App.docx