Louisiana Hurricane Loss Mitigation Survey Form
Instructions: The homeowner/policyholder shall complete Section I. A qualified inspector shall complete Section II and sign Section III.
Section I : Insured Information
Applicant's/Insured's Name ___________________________
Location Address*
___________________________
___________________________
Applicant's / Insured's phone number (___) ________________
Home or Business Phone Indicator H or B
The inspection shall be conducted on each occupiable dwelling on the policy. This survey form does not pertain to accessory structures such as detached garages, storage sheds, barns, etc. Please circle the appropriate answer to each question.
Section II : Inspection Survey
1) BUILDING CODE: To what building or residential code was the dwelling constructed? A) Louisiana State Uniform Construction CodeB) Certified by IBHS as a Fortified for Safer Living structure and built above the requirements of the Louisiana State Uniform Construction CodeC) Neither of the above; built to another code (specify) ________________________________
D) Unknown, unidentified, or no code2) BASIC DESIGN WIND SPEED: What was the Basic Design Wind Speed used to design and construct the dwelling? (if in fastest mile speed, convert to 3-second gust) A) Less than or equal to 90-mph (3-second gust)B) Greater than 90-mph and less than or equal to 100-mph (3-second gust)C) Greater than 100-mph and less than or equal to 110-mph (3-second gust)D) Greater than 110-mph and less than or equal to 120-mph (3-second gust)E) Greater than 120-mph and less than or equal to 130-mph (3-second gust)F) Greater than 130-mph and less than or equal to 140-mph (3-second gust)G) Greater than 140-mph and less than or equal to 150-mph (3-second gust)H) Greater than or equal to150-mph (3-second gust)I) Unknown, unidentified, or no Basic Wind Speed3) EXPOSURE CATEGORY: What Exposure Category was used to design and construct the dwelling? (as defined by ASCE 7) Unknown, unidentified, or no Exposure Category
4) SECONDARY ROOF WATER INTRUSION SYSTEM: Is there a complete secondary roof water intrusion system installed over all dwelling roof areas? Y) Yes, on all roof areasU) Unknown or Unidentified5) EXTENT OF WIND BORNE DEBRIS PROTECTION: To what extent do the building envelope openings have wind borne debris protection - either protected with external protection devices or deemed impact-resistant through building code approved impact testing? ( Building envelope openings include, but are not limited to: windows, swinging doors, sliding doors, garage doors, skylights, and door sidelights.)
A) All Openings - All building envelope openings with and without glass/glazing, including garage doors (if garage doors exist on dwelling or if no garage door exists on dwelling), have wind borne debris protection.B) All Openings (except garage doors) - All building envelope openings with and without glass/glazing, excluding garage doors (if garage doors exist on dwelling), have wind borne debris protection.C) All Glass/Glazed Openings and Some Openings without Glazing - All building envelope openings with glass/glazing and some building openings without glass/glazing, excluding garage doors, have wind borne debris protection. To be completed by Insurer: Insurer: _______________ Policy Number: _________ Policy type: ____________ Agent: ________________ |
D) Only Glass/Glazed Openings - All building envelope openings with glass/glazing have wind borne debris protection.E) Some Glass/Glazed Openings - Some building envelope openings with glass/glazing have wind borne debris protection, but not all.F) No wind borne debris protection is provided on any glass/glazed building envelope openings. U) Unknown or unidentified
6) TYPE OF WIND BORNE DEBRIS PROTECTION: What is the weakest form of wind borne debris protection used on the structure? (listed in descending order from strongest to weakest) A) Building envelope opening products:Have passed the following cyclic loading and windborne debris impact tests [ASTM E 1886 and ASTM E 1996 (Missiles D or E)] or [Miami-Dade TAS 201 and TAS 203] or [ANSI/DASMA 115 for garage doors only]; and are approved by and included in the State of Florida Product Approval System or the Miami-Dade Code Compliance Office Product Approval System; or
Are protected with an external protection device that has passed the following cyclic loading and windborne debris impact tests [ASTM E 1886 and ASTM E 1996 (Missiles D or E)] or [Miami-Dade TAS 201 and TAS 203]; and are approved by and included in the State of Florida Product Approval System or the Miami-Dade Code Compliance Office Product Approval System.
B) External protection devices that cannot be identified as meeting the requirements in Answer A.C) Wood structural panels (plywood or OSB)U) Unknown or unidentifiedX) Not applicable because there is no wind borne debris protection.7) ROOF GEOMETRY: What is the roof shape(s)? (Porches or carports that are not structurally connected to the main roof system are not considered in the roof geometry determination) A) Total Hip Roof Hip roof covering entire structureB) Partial Hip Roof Hip roof with no other roof shapes greater than 50% of any major wall lengthO) Other Any other roof shape or combination of roof shapes including hip, gable, flat, gambrel, mansard, and other roof shapes8) ROOF COVERING SYSTEM: If predominant roof covering on the dwelling is asphalt shingles, have the asphalt shingles passed either ASTM D3161 (Class F) or ASTM D7158 (Class G or H)? U) Unknown or unidentifiedX) Not applicable because predominant roof covering is not asphalt shingles9) AGE OF ROOF COVERING: In what year was the roof covering installed? 10) PREDOMINANT ROOF DECK MATERIAL & ATTACHMENT: What are the predominant roof deck material and its attachment to the dwelling structure below? Type of Roof Deck: ________________________________
Size and Type of Fastener: ___________________________
Spacing of Fasteners: _______________________________
11) ROOF-WALL CONNECTION TYPE: What is the weakest form of Roof-Wall Connector used on the dwelling? (listed in descending order from strongest to weakest) X) Not applicable as roof deck is metal roof deck (pan type), precast concrete panels, or poured-in-place concreteU) Unknown or Unidentified12) GABLE ROOF BRACING: Are the gable roof structure bracing members and system designed and installed in accordance to the Louisiana State Uniform Construction Code? X) Does not apply because there are no gable or gambrel roof shapesU) Unknown or Unidentified13) FOUNDATION RESTRAINT: Are the floor-to-foundation connections designed and installed in accordance to the Louisiana State Uniform Construction Code? U) Unknown or Unidentified Section III - To be completed by a Qualified Professional as specified below:
I certify that I am a Building Code Enforcement Officer, or a Third-Party Provider, as defined by Louisiana Revised Statute or applicable Administrative Rule. I am registered with the Louisiana State Uniform Construction Code Council and authorized, by that registry, to perform residential building inspections for compliance with the Louisiana State Uniform Construction Code. I have conducted an inspection of the structure, and reviewed all construction documents and building product specifications necessary to accurately answer the questions in this inspection survey, and certify that, to the best of my knowledge, all questions are answered truthfully and correctly.
Name (please print): ________________________________
Firm name: _______________________________________
Title (vendor, owner, officer, or partner): _______________
State of Louisiana license number: ____________________
Signature: ___________________________ Date ________
Insureds' Signatures: __ _________________ Date ________
__________________ Date ________
La. Admin. Code tit. 37, § XIII-12721
Promulgated by the Department of Insurance, Office of the Commissioner, LR 34:91 (January 2008).AUTHORITY NOTE: Promulgated in accordance with R.S. 22:3 to enforce the provisions of R.S. 22:1426.