Universal wording updates to improve clarity and intent were made to all FIG text for this form on 06/30/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 862 LA (2009/06)
Louisiana Property Supplement -
Louisiana Hurricane Loss
Mitigation Survey Form
ACORD 862 LA, Louisiana Property Supplement - Louisiana
Hurricane Loss Mitigation Survey Form, complies with LA Regulation 94. Buildings
eligible for hurricane loss mitigation credits must be inspected by a qualified professional.
In accordance with the regulation, the building inspector must use this form.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Agent
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
IDENTIFICATION SECTION Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION Policy Type
Enter text: The description of the type of policy issued to the insured.
SECTION I: INSURED
INFORMATION
Applicant(s) / Insured's Name(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SECTION I: INSURED
INFORMATION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SECTION I: INSURED
INFORMATION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SECTION I: INSURED
INFORMATION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SECTION I: INSURED
INFORMATION
Applicant / Insured's Phone
Number
Enter number: The named insured's primary phone number.
SECTION I: INSURED
INFORMATION
Check box - Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
SECTION I: INSURED
INFORMATION
Check box - Business
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
ACORD 862 LA (2009/06)
1 of 9
Section Name
Field Name
Field and/or Section Description
SECTION I: INSURED
INFORMATION
Location Address
Enter text: The first address line of the physical location.
SECTION I: INSURED
INFORMATION
Enter text: The second address line of the physical location.
SECTION I: INSURED
INFORMATION
Enter text: The city of the physical location.
SECTION I: INSURED
INFORMATION
Enter text: The county of the location.
SECTION I: INSURED
INFORMATION
Enter code: The state or province of the physical location.
SECTION I: INSURED
INFORMATION
Enter code: The postal code of the physical location.
SECTION II: INSPECTION
SURVEY
Building Code - A) Louisiana State
Uniform Construction Code
Check the box (if applicable): Indicates the building or residential code the dwelling
constructed to is the State Uniform Code.
SECTION II: INSPECTION
SURVEY
Building Code - B) Certified by
IBHS as a Fortified for Safer Living
structure
Check the box (if applicable): Indicates the building or residential code the dwelling
constructed to is IBHS Certified.
SECTION II: INSPECTION
SURVEY
Building Code -C) Neither of the
above; built to another code
(specify)
Check the box (if applicable): Indicates the building or residential code the dwelling
constructed to is other than those listed.
SECTION II: INSPECTION
SURVEY
Building Code -Another Code
Enter text: The description of the building or residential code the dwelling constructed to.
SECTION II: INSPECTION
SURVEY
Building Code - D) Unknown,
unidentified, or no code
Check the box (if applicable): Indicates the building or residential code the dwelling
constructed to is unknown, unidentified, or no code.
SECTION II: INSPECTION
SURVEY
Basic Design Wind Speed - A)
Less than or equal to 90-mph (3-
second gust)
Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
construct the dwelling is less than or equal to 90 mph (if in fastest mile speed, convert to
3-second gust).
SECTION II: INSPECTION
SURVEY
Basic Design Wind Speed -B)
Greater than 90-mph and less than
or equal to 100-mph (3-second
gust)
Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
construct the dwelling is greater than 90 mph and less than or equal to 100 mph (if in
fastest mile speed, convert to 3-second gust).
SECTION II: INSPECTION
SURVEY
Basic Design Wind Speed -C)
Greater than 100-mph and less
than or equal to 110-mph (3-
second gust)
Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
construct the dwelling is greater than 100 mph and less than or equal to 110 mph (if in
fastest mile speed, convert to 3-second gust).
ACORD 862 LA (2009/06)
2 of 9
Section Name
Field Name
Field and/or Section Description
SECTION II: INSPECTION
SURVEY
Basic Design Wind Speed -D)
Greater than 110-mph and less
than or equal to 120-mph (3-
second gust)
Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
construct the dwelling is greater than 110 mph and less than or equal to 120 mph (if in
fastest mile speed, convert to 3-second gust).
SECTION II: INSPECTION
SURVEY
Basic Design Wind Speed -E)
Greater than 120-mph and less
than or equal to 130-mph (3-
second gust)
Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
construct the dwelling is greater than 120 mph and less than or equal to 130 mph (if in
fastest mile speed, convert to 3-second gust).
SECTION II: INSPECTION
SURVEY
Basic Design Wind Speed -F)
Greater than 130-mph and less
than or equal to 140-mph (3-
second gust)
Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
construct the dwelling is greater than 130 mph and less than or equal to 140 mph (if in
fastest mile speed, convert to 3-second gust).
SECTION II: INSPECTION
SURVEY
Basic Design Wind Speed -G)
Greater than 140-mph and less
than or equal to 150-mph (3-
second gust)
Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
construct the dwelling is greater than 140 mph and less than or equal to 150 mph (if in
fastest mile speed, convert to 3-second gust).
SECTION II: INSPECTION
SURVEY
Basic Design Wind Speed -H)
Greater than or equal to 150-mph
(3-second gust)
Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
construct the dwelling is greater than or equal to 150 mph (if in fastest mile speed, convert
to 3-second gust).
SECTION II: INSPECTION
SURVEY
Basic Design Wind Speed -I)
Unknown, unidentified, or no
Basic Wind speed
Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
construct the dwelling is unknown, unidentified, or no basic wind speed.
SECTION II: INSPECTION
SURVEY
Exposure - A)
Check the box (if applicable): Indicates the Exposure Category A, as defined by ASCE 7,
was used to design and construct the dwelling.
SECTION II: INSPECTION
SURVEY
Exposure - B)
Check the box (if applicable): Indicates the Exposure Category B, as defined by ASCE 7,
was used to design and construct the dwelling.
SECTION II: INSPECTION
SURVEY
Exposure - C)
Check the box (if applicable): Indicates the Exposure Category C, as defined by ASCE 7,
was used to design and construct the dwelling.
SECTION II: INSPECTION
SURVEY
Exposure - D)
Check the box (if applicable): Indicates the Exposure Category D, as defined by ASCE 7,
was used to design and construct the dwelling.
SECTION II: INSPECTION
SURVEY
Exposure - Unknown, unidentified,
or no Exposure Category
Check the box (if applicable): Indicates the Exposure Category, as defined by ASCE 7,
used to design and construct the dwelling is unknown or unidentified.
SECTION II: INSPECTION
SURVEY
Secondary Roof Water Intrusion
System-Y) Yes, on all roof areas
Check the box (if applicable): Indicates there is a secondary roof water intrusion system
installed over all dwelling roof areas.
ACORD 862 LA (2009/06)
3 of 9
Section Name
Field Name
Field and/or Section Description
SECTION II: INSPECTION
SURVEY
Secondary Roof Water Intrusion
System-N) No
Check the box (if applicable): Indicates there no secondary roof water intrusion system
installed over all dwelling roof areas.
SECTION II: INSPECTION
SURVEY
Secondary Roof Water Intrusion
System-U) Unknown or
Unidentified
Check the box (if applicable): Indicates the existence of a secondary roof water intrusion
system is unknown or unidentified.
SECTION II: INSPECTION
SURVEY
Extent of Windborne Debris
Protection- A) All Openings - All
building envelope openings with
and without glass / glazing,
including garage doors
Check the box (if applicable): Indicates the extent 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 is 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. Building envelope openings include, but are not limited to windows,
swinging doors, sliding doors, garage doors, skylights, and door sidelights.
SECTION II: INSPECTION
SURVEY
Extent of Windborne Debris
Protection- B) All Openings
(except garage doors) - All
building envelope openings with
and without glass / glazing,
excluding garage doors
Check the box (if applicable): Indicates the extent 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 is 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.
Building envelope openings include, but are not limited to windows, swinging doors, sliding
doors, garage doors, skylights, and door sidelights.
SECTION II: INSPECTION
SURVEY
Extent of Windborne Debris
Protection- C) All Glass / Glazed
Openings and Some Openings
without Glazing
Check the box (if applicable): Indicates the extent 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 is 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. Building envelope openings include, but are not limited to
windows, swinging doors, sliding doors, garage doors, skylights, and door sidelights.
SECTION II: INSPECTION
SURVEY
Extent of Windborne Debris
Protection- D) Only Glass / Glazed
Openings - All building envelope
openings with glass / glazing have
wind borne debris protection.
Check the box (if applicable): Indicates the extent 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 is D - Only Glass / Glazed
Openings - All building envelope openings with glass / glazing have wind borne debris
protection. Building envelope openings include, but are not limited to windows, swinging
doors, sliding doors, garage doors, skylights, and door sidelights.
ACORD 862 LA (2009/06)
4 of 9
Section Name
Field Name
Field and/or Section Description
SECTION II: INSPECTION
SURVEY
Extent of Windborne Debris
Protection- E) Some Glass /
Glazed Openings - Some building
envelope openings with glass /
glazing have wind borne debris
protection, but not all.
Check the box (if applicable): Indicates the extent 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 is E - Some Glass /
Glazed Openings - Some building envelope openings with glass / glazing have wind borne
debris protection. Building envelope openings include, but are not limited to windows,
swinging doors, sliding doors, garage doors, skylights, and door sidelights.
SECTION II: INSPECTION
SURVEY
Extent of Windborne Debris
Protection- F) No wind borne
debris protection is provided on
any glass / glazed building
envelope openings
Check the box (if applicable): Indicates the extent 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 is F - No wind borne
debris protection is provided on any glass / glazed building envelope openings Building
envelope openings include, but are not limited to windows, swinging doors, sliding doors,
garage doors, skylights, and door sidelights.
SECTION II: INSPECTION
SURVEY
Extent of Windborne Debris
Protection- U) Unknown or
Unidentified
Check the box (if applicable): Indicates the extent 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 is U) Unknown or
Unidentified. Building envelope openings include, but are not limited to windows, swinging
doors, sliding doors, garage doors, skylights, and door sidelights.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
SECTION II: INSPECTION
SURVEY (continued)
Type of Wind Borne Debris
Protection- A) Building envelope
opening products: Have passed
the following cyclic loading and
windborne debris impact tests
listed
Check the box (if applicable): Indicates the weakest type of wind-borne debris protection
used on the structure is Building envelope opening products:
Have passed the following cyclic loading and wind-borne 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 wind-borne debris impact tests 0 [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.
ACORD 862 LA (2009/06)
5 of 9
Section Name
Field Name
Field and/or Section Description
SECTION II: INSPECTION
SURVEY (continued)
Type of Wind Borne Debris
Protection- B) External protection
devices that cannot be identified
as meeting the requirements in
Answer A
Check the box (if applicable): Indicates the weakest type of wind-borne debris protection
used on the structure is External Protection Devices that have not passed the following
wind-borne debris impact test:
0 [ASTM E 1886 and ASTM E 1996 (Missiles D or E)] or [Miami-Dade TAS 201 and TAS
203]; or are not approved by and included in the State of Florida Product Approval System
or the Miami-Dade Code Compliance Office Product Approval System..
SECTION II: INSPECTION
SURVEY (continued)
Type of Wind Borne Debris
Protection- C) Wood structural
panels (plywood or OSB)
Check the box (if applicable): Indicates the weakest type of wind-borne debris protection
used on the structure is Wood Structural Panels (plywood or OSB).
SECTION II: INSPECTION
SURVEY (continued)
Type of Wind Borne Debris
Protection- U) Unknown or
Unidentified
Check the box (if applicable): Indicates the weakest type of wind-borne debris protection
used on the structure is unknown or unidentified.
SECTION II: INSPECTION
SURVEY (continued)
Type of Wind Borne Debris
Protection- X) Not applicable
because there is no wind borne
debris protection.
Check the box (if applicable): Indicates the weakest type of wind-borne debris protection
used on the structure is not applicable because there is no wind-borne debris protection.
SECTION II: INSPECTION
SURVEY (continued)
Roof Geometry- A) Total Hip roof -
Hip roof covering entire structure
Check the box (if applicable): Indicates the shape of the roof is a total hip roof - hip roof
covering the entire structure (porches or carports that are not structurally connected to the
main roof system are not considered in the roof geometry determination).
SECTION II: INSPECTION
SURVEY (continued)
Roof Geometry- B) Partial Hip roof
- Hip roof with no other roof
shapes greater than 50% of any
major wall length
Check the box (if applicable): Indicates the shape of the roof is a partial hip roof - hip roof
with no other roof shapes greater than 50% of any major wall length (porches or carports
that are not structurally connected to the main roof system are not considered in the roof
geometry determination).
SECTION II: INSPECTION
SURVEY (continued)
Roof Geometry- O) Other - Any
other roof shape or combination of
roof shapes including hip, gable,
flat gambrel, mansard, and other
roof shapes
Check the box (if applicable): Indicates the shape of the roof is other than those listed
(porches or carports that are not structurally connected to the main roof system are not
considered in the roof geometry determination). This may include hip, gable, flat gambrel,
mansard, and other roof shapes.
SECTION II: INSPECTION
SURVEY (continued)
Roof Covering System- Y) Yes
Check the box (if applicable): Indicates the predominant roof covering on the dwelling is
asphalt shingles that have passed either ASTM D3161 (Class F) or ASTM D7158 (Class
G or H).
ACORD 862 LA (2009/06)
6 of 9
Section Name
Field Name
Field and/or Section Description
SECTION II: INSPECTION
SURVEY (continued)
Roof Covering System- N) No
Check the box (if applicable): Indicates the predominant roof covering on the dwelling is
not asphalt shingles that have passed either ASTM D3161 (Class F) or ASTM D7158
(Class G or H).
SECTION II: INSPECTION
SURVEY (continued)
Roof Covering System- U)
Unknown or Unidentified
Check the box (if applicable): Indicates the predominant roof covering on the dwelling is
asphalt shingles but the status of the ASTM 3161 (Class F) or ASTM D7158 (Class G or
H) tests are unknown or unidentified.
SECTION II: INSPECTION
SURVEY (continued)
Roof Covering System- X) Not
applicable because predominant
roof covering is not asphalt
shingles
Check the box (if applicable): Indicates the predominant roof covering on the dwelling is
not asphalt shingles.
SECTION II: INSPECTION
SURVEY (continued)
Age of Roof Covering- A)
Check the box (if applicable): Indicates the year the roof covering system was installed is
known.
SECTION II: INSPECTION
SURVEY (continued)
Age of Roof Covering- Year
Enter year: The year the roof covering system was installed.
SECTION II: INSPECTION
SURVEY (continued)
Age of Roof Covering- U)
Unknown
Check the box (if applicable): Indicates the year the roof covering system was installed is
unknown.
SECTION II: INSPECTION
SURVEY (continued)
Type of Roof Deck:
Enter text: The predominant roof deck material.
SECTION II: INSPECTION
SURVEY (continued)
Size and Type of Fastener:
Enter text: The size and type of fastener used for the roof deck.
SECTION II: INSPECTION
SURVEY (continued)
Spacing of Fasteners:
Enter text: The spacing of the roof deck fasteners.
SECTION II: INSPECTION
SURVEY (continued)
Roof Wall- A) Double Wraps
Check the box (if applicable): Indicates the weakest form of roof-wall connectors used on
the dwelling are double wraps.
SECTION II: INSPECTION
SURVEY (continued)
Roof Wall- B) Single Wraps
Check the box (if applicable): Indicates the weakest form of roof-wall connectors used on
the dwelling are single wraps.
SECTION II: INSPECTION
SURVEY (continued)
Roof Wall- C) Clips
Check the box (if applicable): Indicates the weakest form of roof-wall connectors used on
the dwelling are clips.
SECTION II: INSPECTION
SURVEY (continued)
Roof Wall- D) Toenails
Check the box (if applicable): Indicates the weakest form of roof-wall connectors used on
the dwelling are toenails.
SECTION II: INSPECTION
SURVEY (continued)
Roof Wall- E) None
Check the box (if applicable): Indicates none was selected as the weakest form of roof-
wall connectors used on the dwelling.
ACORD 862 LA (2009/06)
7 of 9
Section Name
Field Name
Field and/or Section Description
SECTION II: INSPECTION
SURVEY (continued)
Roof Wall- X) Not applicable as
roof deck is metal roof deck (pan
type), precast concrete panels, or
poured-in-place concrete
Check the box (if applicable): Indicates the weakest form of roof-wall connectors is not
applicable as the roof deck is metal (pan type), precast concrete panels, or poured-in-
place concrete.
SECTION II: INSPECTION
SURVEY (continued)
Roof Wall- U) Unknown or
Unidentified
Check the box (if applicable): Indicates the weakest form of roof-wall connectors is
unknown or unidentified.
SECTION II: INSPECTION
SURVEY (continued)
Gable Roof Bracing- Y) Yes
Check the box (if applicable): Indicates the gable roof structure bracing members and
system is designed and installed in accordance to the State Uniform Construction Code.
SECTION II: INSPECTION
SURVEY (continued)
Gable Roof Bracing- N) No
Check the box (if applicable): Indicates the gable roof structure bracing members and
system is not designed and installed in accordance to the State Uniform Construction
Code.
SECTION II: INSPECTION
SURVEY (continued)
Gable Roof Bracing- X) Does not
apply because there are no gable
or gambrel roof shapes
Check the box (if applicable): Indicates the question is not applicable because there are
no gable or gambrel roof shapes.
SECTION II: INSPECTION
SURVEY (continued)
Gable Roof Bracing- U) Unknown
or Unidentified
Check the box (if applicable): Indicates it is unknown or unidentified if the gable roof
structure bracing members and system is designed and installed in accordance to the
State Uniform Construction Code.
SECTION II: INSPECTION
SURVEY (continued)
Foundation Restraint- Y) Yes
Check the box (if applicable): Indicates there are floor-to-foundation connections designed
and installed in accordance with the State Uniform Construction Code.
SECTION II: INSPECTION
SURVEY (continued)
Foundation Restraint- N) No
Check the box (if applicable): Indicates there are not floor-to-foundation connections
designed and installed in accordance with the State Uniform Construction Code.
SECTION II: INSPECTION
SURVEY (continued)
Foundation Restraint- U)
Unknown or Unidentified
Check the box (if applicable): Indicates it is unknown or unidentified if there are floor-to-
foundation connections designed and installed in accordance with the State Uniform
Construction Code.
SECTION III:
Name (Please Type or Print)
Enter text: The full name of the individual conducting the inspection.
SECTION III:
Firm Name
Enter text: The name of the firm of the individual conducting the inspection.
SECTION III:
Title (Vendor, Owner, Officer, or
Partner
Enter text: The title of the individual conducting the inspection.
SECTION III:
State of Louisiana License
Number
Enter identifier: The state license number of the individual conducting the inspection.
SECTION III:
Signature
Sign here: The signature of the inspector.
SECTION III:
Date
Enter date: The date the form was signed by the inspector.
SECTION III:
Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SECTION III:
Date
Enter date: The date the form was signed by the named insured.
ACORD 862 LA (2009/06)
8 of 9
Section Name
Field Name
Field and/or Section Description
SECTION III:
Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SECTION III:
Date
Enter date: The date the form was signed by the named insured.
SECTION III:
Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SECTION III:
Date
Enter date: The date the form was signed by the named insured.
SECTION III:
Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SECTION III:
Date
Enter date: The date the form was signed by the named insured.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 862 LA (2009/06)
9 of 9