4-Point Inspection Form

Insured/Applicant Name: Sample Customer	Application / Policy #:
Address Inspected: 123 Sample Street, Sample City, FL 00000
Actual Year Built: 2005	Date Inspected: 07/10/2026

Minimum Photo Requirements:

✔ Dwelling: Each side ✔ Roof: Each slope ✔ Plumbing: Water heater (incl TPRV), under cabinet plumbing/drains, exposed valves

✔ Main electrical service panel with interior door label ✔ Electrical box with panel off ✔ All hazards or deficiencies noted in this report

A Florida-licensed inspector must complete, sign and date this form.

Be advised that Underwriting will rely on the information in this sample form, or a similar form, that is obtained from the Florida licensed professional of your choice. This information only is used to determine insurability and is not a warranty or assurance of the suitability, fitness or longevity of any of the systems inspected.

Electrical System
Separate documentation of any single strand aluminum wiring remediation must be provided and certified by a licensed electrician.

Main Panel

Type: ✔ Circuit breaker Fuse

Total Amps: 150

Is amperage sufficient for current usage? ✔ Yes No (explain)

Second Panel

Type: ✔ Circuit breaker Fuse

Total Amps: 150

Is amperage sufficient for current usage? ✔ Yes No (explain)

Indicate presence of any of the following:

Cloth wiring

Active knob and tube

Branch circuit aluminum wiring (If present, describe the usage of all aluminum wiring):

* If single strand (aluminum branch) wiring, provide details of all remediation. Separate documentation of all work must be provided.

Connections repaired via COPALUM crimp

Connections repaired via AlumiConn

Hazards Present

Blowing fuses

Tripping breakers

Empty sockets

Loose wiring

Improper grounding

Corrosion

Over fusing

Double taps

Exposed wiring

Unsafe wiring

Improper breaker size

Scorching

Other (explain)

General condition of the electrical system: ✔ Satisfactory Unsatisfactory (explain)

Supplemental information

Main Panel

Panel age: 21

Year last updated: 2005

Brand/Model: Siemens

Second Panel

Panel age: 21

Year last updated: 2005

Brand/Model: Siemens

Wiring Type(s)

✔ Copper	Copper Clad AL	✔ NM, BX or Conduit
Single Strand AL	Cloth (Knob & Tube)	Other
✔ Multistrand AL	Cloth Jacket Rubber Insulated

4-Point Inspection Form

HVAC System

Central AC: ✔ Yes No

Central heat: ✔ Yes No

Are the heating, ventilation and air conditioning systems in good working order? ✔ Yes No (explain)

Date of last HVAC servicing/inspection:

Hazards Present

Is a wood-burning stove or central gas fireplace present? Yes ✔ No

Space heater used as primary heat source? Yes ✔ No

Does the air handler/condensate line or drain pan show any signs of blockage or leakage, including water damage to the surrounding area?

Yes ✔ No

Supplemental Information

Age of system: 0

Year last updated: 2026

(Please attach photo(s) of HVAC equipment, including dated manufacturer's plate)

Plumbing System

Is there a temperature pressure relief valve on the water heater? ✔ Yes No

Is there any indication of an active leak? Yes ✔ No

Is there any indication of a prior leak? Yes ✔ No

Water heater location: Closet

General condition of the following plumbing fixtures and connections to appliances:

	Satisfactory		Satisfactory	N/A
Dishwasher	✔	Toilets	✔
Refrigerator	✔	Sinks	✔
Washing machine	✔	Sump pump		✔
Water heater	✔	Main shut off valve	✔
Showers/Tubs	✔	All other visible	✔

Supplemental Information

Age of Piping Supply System:

✔ Original to home

Completely re-piped

Partially re-piped

Age of water heater 1 year

(Provide year and extent of renovation in the comments below)

Age of Piping Drain System:

✔ Original to home

Completely re-piped

Partially re-piped

Type of pipes (check all that apply)

Copper PEX

PEX Year Installed:

✔ PVC/CPVC Other (specify)

Galvanized

Cast Iron

Polybutylene

ABS

4-Point Inspection Form

Roof (With photos of each roof slope, this section can take the place of the Roof Inspection Form.)

Predominant Roof

Covering material: Architectural / Asphalt Shingles

Roof age (years): 1

Remaining useful life (years): 19

Date of last roofing permit: 10/14/2025

Date of last update: 2025

If updated (check one):

✔ Full replacement

Partial replacement

Overall condition:

✔ Satisfactory

Unsatisfactory (explain below)

Secondary Roof

Covering material:

Roof age (years):

Remaining useful life (years):

Date of last roofing permit:

Date of last update:

If updated (check one):

Full replacement

Partial replacement

Overall condition:

Satisfactory

Unsatisfactory (explain below)

Any visible signs of damage / deterioration?

(check all that apply and explain below)

Cracking

Cupping/curling

Excessive granule loss

Exposed asphalt

Exposed felt

Missing/loose/cracked tabs or tiles

Soft spots in decking

Visible hail damage

Any visible signs of damage / deterioration?

(check all that apply and explain below)

Cracking

Cupping/curling

Excessive granule loss

Exposed asphalt

Exposed felt

Missing/loose/cracked tabs or tiles

Soft spots in decking

Visible hail damage

Any visible signs of leaks? Yes ✔ No

Attic/underside of decking Yes ✔ No

Interior ceilings Yes ✔ No

Any visible signs of leaks? Yes ✔ No

Attic/underside of decking Yes ✔ No

Interior ceilings Yes ✔ No

Additional Comments/Observations (use additional pages if needed):

All 4-Point Inspection Forms must be completed and signed by a verifiable Florida-licensed inspector.
I certify that the above statements are true and correct.

Inspector Signature	Owner Title	HI-0000000 License Number	07/10/2026 Date
Sample Inspector Inspector Name	Company Name	Home Inspector License Type	Work Phone

4-Point Inspection Form

4-Point Inspection Form

4-Point Inspection Form

PHOTO APPENDIX