Builders Risk Insurance Quote

Business / General Contractor Name *

Project Address *

Mailing Address (if different)

The applicant is (check all that apply)

Business Structure

Years in Business

Is the applicant a licensed general contractor?

Yes No

Type of Project *

Type of Policy

One-shot policy Reporting form policy

Will the contractor or owner be insuring more than one building / structure on this policy?

Yes No

Construction Material

Protection Class (current ISO Public Protection Classification)

Protection class confirmation (check all that apply)

Contact your fire department for this if you are in a rural area with a volunteer fire department or you pay fire dues Property is within 5 road miles of the responding fire station and within 1,000 feet of a creditable water supply

Number of Stories (if over 7, underwriter approval required)

Square Footage (INCLUDES basement)

Type of Property

Residential (1-4 Single Family Dwellings/Units) Commercial

Intended Occupancy

Will the structure be occupied at any time during the policy term?

Yes No

Is this a model home?

Yes No

Original Year Built (existing structure)

Year the Roof Was Last Updated

Is the structure modular? (if yes, underwriting approval required and modular questions will be asked)

Yes No

Does it have a continuous masonry foundation and a shingled roof?

Yes No

Will this project involve installation of solar?

Yes No

Total Completed Value of Any One Structure ($ - greater than $3,000,000 requires underwriter approval) *

Total Completed Value of All Covered Property ($ - greater than $3,000,000 requires underwriter approval) *

Deductible Requested

Other Deductible Amount ($)

Soft Costs to Include ($, if any - permits, architect/engineering fees, etc.)

Value of the Existing Building to Insure ($)

General Liability Limits Requested

Add $5,000 of theft coverage?

Yes No Not Sure

Policy Period

Expected Completion Date of Project

Is the builder's name different than the named insured?

Yes No

Builder's Name

Does the builder / remodeler / owner / GC have at least 2 years experience? (If no, the risk is not eligible)

Yes No

Builder's Experience (years, similar projects completed)

Number of structures / projects projected for the next 12 months

1-2 3-50 Other

How many?

Has the builder / remodeler and/or the structure itself had any single loss or damage over $10,000 in the last 3 years? (include insured and uninsured losses)

Yes No

Loss Details

Mortgagee / Lender Name and Address (if any)

Has the project started?

Yes No

Date Started

Percent Complete (%)

Has the project been dormant or delayed? If so, how long and why?

Has there been a change in the general contractor?

Yes No

Any previous damage at this location as a result of quake, flood, wind, fire or vandalism? (include insured and uninsured damages)

Yes No

Explain all losses including the peril involved, the amount of the loss and the date of the loss (if yes, underwriter approval required)

Is the job site completely fenced with gates that lock after hours?

Yes No

Height of Fencing

Is there security lighting at the job site?

Yes No

Is guard service employed on site?

Yes No

Guard Hours (weekends only, off-hours only, 24/7, other)

Are portable fire extinguishers kept at the site?

Yes No

Distance to the Nearest Fire Hydrant (feet)

Distance to the Nearest Responding Fire Department (miles)

Hazardous or flammable materials stored on site, and how they are stored

Is the renovation structural or non-structural?

Structural Non-Structural Both

Any hot work (welding, cutting, torch work, soldering, grinding)?

Yes No

Any electrical work?

Yes No

Is there an operating central station burglar alarm?

Yes No

Is there an operating central station fire alarm?

Yes No

Is the structure sprinklered, and is the system turned on?

Sprinklered - system on Sprinklered - system off Not sprinklered

Have you had builders risk coverage before?

Yes No

In the past 3 years, has any company cancelled, declined or refused similar insurance?

Yes No

Please explain

Has the applicant declared bankruptcy or been in receivership in the past 5 years?

Yes No

Date(s)

Do you have coverage now? *

Yes No

Who is your current insurance company? *

When does your insurance expire?

Policy Effective Date (12:01 a.m. standard time at the mailing address above) *

Notes

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