Farm and Ranch Swimming Pool Questionnaire
Named Insured - _______________________________
Policy Number - _________________
1. Size and depths:
Length: _______ ft. Width: ________ ft.
Max. Depth: ______ ft. Min. Depth: _______ ft.
Depths Marked? Yes No Clearly visible from all sides? Yes No
2. Construction of Pool:
Gunite/Concrete Vinyl Other: _________________
3. Type of Pool:
In-ground Above Ground Age: __________
4. Fencing:
Height : ________ ft. Construction Material: _________________
Gates/Doors Self-Closing and Self-Latching? Yes No
Gates/Doors locked when closed/at night? Yes No
5. Pool Deck/Patio:
Slip-resistant? Yes No Self-Draining? Yes No
6. Diving Board(s) and Other Exposures:
Number: _______ Height over water: _________ ft.
Depth of Water under the Diving Board: _________ ft.
Water Slide? Yes No Height above Pool Deck: _____ ft.
Spa/Jacuzzi? Yes No
Included in the Pool: Yes No or
Separate: Yes No
7. Safety:
Life rings/Shepard’s hook available/accessible? Yes No
Ground fault interrupter on pool and area lighting? Yes No
Are there Ladders to allow safe access out of pool? Yes No
Any unsupervised activities? Yes No
If Yes, explain: ________________________________________
Does the insured have a gate and/or water alarm? Yes No
Are the Chemicals checked on a regular basis? Yes No
Where are the pool chemicals stored? ________________________
Named Insured’s Signature: _______________________ Date: _________
*** Please attach a Photograph(s) of the Pool and Surrounding Area ***
02/2006
click to sign
signature
click to edit
![]()
