"*" indicates required fields Δ Welcome to the West Side Mutual Self Inspection. This form may take up to 1 hour to complete. This property survey is solely for company underwriting purposes. Underwriting surveys and resulting request are for the benefit of this company and not for any other person. This survey is not intended to be, nor should it be, considered a substitute for inspections of the various heating, electrical and mechanical systems on your property. Those systems should be inspected and maintained by qualified professionals. This survey was not made to determine or warrant that the property or operation are safe or healthful or in compliance with any law, rule or regulation. Message and data rates may apply. Consent* I agree to the disclaimer above Please answer a few questions so we can locate the correct policy for this self inspection.Policy NumberPlease provide your insurance policy number (if known)Policyholder Name* First Last Policy Holder Phone*Policy Holder Email* Please provide us some details on the inspection property itself.Property Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How many outbuildings are on the property?(buildings not attached to the dwelling)Please enter a number from 0 to 10. What is the approximate age of your roof?Select1 to 5 years old5 to 10 years old10 to 15 years oldOlder than 15 years Type of roof materialSelectAsphalt ShinglesMetal RoofClay or TileSlateRubberWoodFlat roofOtherUnsureOther Roofing Material Do you have any pets on your property (excluding livestock)?* Yes No How many pets?*Please enter a number from 0 to 10.Please describe your pet and their breed?Please describe your pets and their breeds? Do you have livestock or other animals on your property (excluding domesticated pets)?* Yes No Please describe the livestock?*(for example: 3 chickens, 3 goats) Smoke detectors must be replaced every 6 to 10 years depending on the manufacturers requirements. Smoke detectors that are expired may not function correctly even with fresh batteries and should be discarded. If you have any questions about smoke detectors, please contact your local fire department.Are the smoke detectors working and placed in areas as required by law or local ordinance?* Yes No How recently has a self test been performed on the smoke detectors in your home?*SelectWithin the last monthWithin the last 6 monthsWithin the last yearFurther than one yearSmoke detectors should be checked every 6 months. Make sure to use the self test button on the smoke detector once every 6 months to ensure the device is still functional. Where are fire extinguisher located in your home?* Kitchen Utility room Great room/family room Bedroom Garage Detached shed or storage area Other Area Not Listed No fire extinguishers present Other fire extinguisher location We now have a few questions about the heating and cooling systems present in your home. What is the primary heat source for the home?SelectNatural Gas (LNG)PropaneElectricRadiantWoodGeothermalSplit systemHeating oilSteamOther Does the home have central air conditioning?* Yes No When was the current central A/C system installed in the home?Select1-5 years ago5-10 years ago10-15 years agoMore than 15 yearsI'm not certain Is there a solid fuel burner present in the home?*This includes corn, wood, or pellet burning stoves. Yes No Who installed your solid fuel burner?*SelectProfessionalSelfUnknownWhere is the solid fuel burner located?*For example: Is it in an attached or detached structure or in your home? Or in the family room or basement? You will now be asked to provide several internal and external photos to your home. Never risk your safety to take a photograph If you cannot safely take a photo of an item, skip uploading that photo and move on to the next item. West Side Mutual can send a trained inspector to take photos if you would like. Please provide us with a photo of the front of your home. The front of your home is the side which faces the street which contains your mailbox. You may need to step back from your home to fit the entire house in the photo. Make sure that the photo includes any attached structures. Example of a photo of the front of a homePhoto of home from front Please provide us with a photo of the left side of your home. The left side of your home is the side that is to your left if you are standing in front of your home, facing it. You may need to step back from your home to fit the entire house in the photo. Make sure that the photo includes any attached structures. Example of a photo of the left side of a homePhoto from Left Please provide us with a photo of the right side of your home. The right side of your home is the side that is to your right if you are standing in front of your home, facing it. You may need to step back from your home to fit the entire house in the photo. Make sure that the photo includes any attached structures. Example of a photo of the right side of a homePhoto from Right Please provide us with a photo of the rear of your home. The rear of your home is the side opposite to the front. You may need to step back from your home to fit the entire house in the photo. Make sure that the photo includes any attached structures. Example of a photo of the rear of a homePhoto from Rear Please provide us with a photo of the roof of your home. Example of a photo of the roof of a homePhoto of Roof Please provide us with a photo of the central A/C unit present on your home. Example of a photo of a central A/C unitPhoto of A/C unit Please provide us with a photo of the location where the electrical meter is located. Example of a photo of electrical service entrancePhoto of Electrical Service Entrance Please provide us with a photo of the outbuilding. Example of a photo of an outbuildingOutbuilding #1 Please provide us with a photo of the outbuilding. Example of a photo of an outbuildingOutbuilding #2 Please provide us with a photo of the outbuilding. Example of a photo of an outbuildingOutbuilding #3 Please provide us with a photo of the outbuilding. Example of a photo of an outbuildingOutbuilding #4 Please provide us with a photo of the outbuilding. Example of a photo of an outbuildingRemaining outbuildingsPlease take photos of the remaining outbuildings and attach them. Drop files here or Select files Accepted file types: jpg, gif, png, jpeg, Max. file size: 10 MB, Max. files: 5. Please provide us with a photo of the solid fuel burner. Example photo of a woodburnerPhoto of solid fuel burner Please provide us with a photo of the warning label on the woodburner. Example of a photo of an woordburner warning labelPhoto of label on solid fuel burner Please provide us with a photo of the main furnace that heats your home. Example of a photo of furnacePhoto of Furnace* Please provide us with a photo of your water heater. Please make sure the release valve pipe (noted with red arrow in example photo) is in view on the photo. Example photo of water heaterPhoto of Water Heater* Please provide us with a photo of your circuit breaker/fuse panel. Please make sure the panel door is open for the photo. Example photo of circuit breaker panelCircuit Breaker / Fuse Panel*(Please open panel and take photos of the breakers/fuses) Please provide us with a photo of your sump pump pit, if you have one. Example photo of a sump pump pit Sump Pump (if applicable)(Please take a photo of the area around the sump pump) Please provide us with photos of your kitchen. Include refrigerator, stove, dishwasher (if applicable), kitchen cabinets and countertop. Example kitchen overview Kitchen Overview*(Please include photos of all appliances, the cabinets and countertop.)Kitchen Overview*(Please include photos of all appliances, the cabinets and countertop.) Please provide us with photos of your bathroom(s). Include the shower/tub, sink and toilet in the photo. Example photo of bathroom overview Bathroom Overview*(Please include photos of shower/tub, sink and toilet.)Bathroom Overview*(Please include photos of shower/tub, sink and toilet.) Any other photos? Any other photos? Comments? You have completed the self inspection form. Please submit your answers!
