Inter-Ocean Insurance Agency
Supplemental to Application

(to be completed separately for each building to be insured)
Property Location: St. Croix   St. Thomas

Mailing Address (include email address at end):
Building Address:

Building Location:HillsideValleyReclaimed Land
(check all that apply)Within 500 ft. from the Sea or a River
 Within 20 ft. from another building structure

1.Insured is:OwnerTenantLessee

2.Other occupants in building:YESNO
 If YES, describe:

3.Building is rented to others:YESNO
 If YES, explain:

4.Occupation of the Building:Private DwellingYESNO
 If Commercial, nature of operations:

5.Year built:

6.Date of major alterations or improvements:
and nature of improvements:

7.Did alterations & improvements include windstorm damage protection?YESNO

8.Roof structure:Reinforced ConcreteExposed Beam
 (check all that apply)Wood TrussesSteel Rafters
 Wood Rafter (open system for corrugated metal)
 Steel Joists with Steel Decking

9.Roof Structure Anchor Systems:Hurricane Clips (secured to bond beam)
 (check all that apply)Re-bar from slab through rafter end

10.Laths or Purlins:N/ANot more than 24" apart.
 More than 24" apart. Specify distance apart:
 Nailed orScrewed to each rafter.

11.Roof Cover:Aluminum or Corrugated MetalPainted
 (check all that apply)Standing SeamEnamelled FinishClay Tile
 Plastic TileMembrane CoatingComposition Shingle

12.Roof Cover Fastening:N/ANailedScrews
 (check all that apply)StapledOther:

13.Intervals Between Fastenings:N/ALess than 8 inches
 More than 8 inches. Specify distance between fastenings:

14.Roof Overhangs:None
 2 Feet2 - 4 FeetOver 4 Feet
 If over 2', please specify exact measurement of overhang:

15.Exterior Walls:Reinforced ConcreteReinforced Concrete Block
 (check all that apply)Hollow Concrete BlockBrick or Stone
 Wood StudSteel Stud
 3-D PanelOther:

16.Exterior Opening Protection:
 Hurricane ShuttersYESNO
 TypeRoof Type SteelHinged Wood
Steel Panels
 Iron Grill WorkYESNO
 Aluminum "Miami" LouversYESNO
 If none of the above, please explain how exterior openings will be protected in the event of a hurricane:
 Protected by:

17.Electrical: Rewired?YESNOIf YES, date?

18.Distance to Fire Department:mile(s)

19.Fire Extinguishers?YESNONumber:
 Properly Tagged and Serviced?YESNO

20.Smoke Detectors?YESNONumber:

21.Open Water Sources:CisternPool Other:

22.Fire Detection/Alarm System?YESNO

23.Burgler Alarm System?YESNO

24.Area of Building:sq. ft.
 Area of Porches/Decks:sq. ft.

Read Before Submitting
The information given in this application for insurance is the basis upon which the company will issue the policy, and will be an integral part of the policy as a warranty to the extent that if any of the questions are answered fraudulantly, or in such a way as to conceal or misrepresent any material fact or the subject thereof, the entire policy shall be void in all its parts.

Inter-Ocean Insurance Agency
7B Peter's Rest Shopping Center
C'sted, VI 00820
Tel: (340)773-4600   Fax: (340)773-4190

Inter-Ocean Insurance Agency
Bucanneer Mall, Ste. 12
St. Thomas, VI 00801
Tel: (340)774-2999   Fax: (340)774-2899