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Builders Risk Insurance
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Request Form
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FAQ
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Insured Information
Named Insured:
Insured Address1:
Insured Address2:
City:
State:
Zip code:
Email Address:
Daytime Phone #:
Fax:
Business Information
Insured Form of business:
Select One
Individual
Partnership
Corporation
LLC
Joint Venture
Other
If Other, describe:
Named Insured Description:
Select One
Owner
Contractor
Owner/Contractor
Is builder/contractor’s name different from named insured:
Yes
No
If yes, enter the builder as another named insured below
:
Does the builder/contractor have at least 2 years experience building/remodeling:
Yes
No
Number of structures built/remodeled during the past 12 months:
1-2
3-50
Other
Number of structures projected for the next 12 months:
1-2
3-50
Other
Has the builder/remodeler had any single loss over $10,000 in the last 3 years
(Include Insured/uninsured losses):
Yes
No
If Yes, include the date, description, and amount of each loss below:
Additional Interest
Interest type:
Select One
Builder
Mortagee
Other
Name:
Address1:
Address2:
City:
State:
Zip code:
Daytime Phone #:
Property Information
State:
County:
Type of project:
Select One
New Construction
Remodeling/Renovation excluding coverage for the existing coverage
Remodeling/Renovation including coverage for the existing structure
Type of Property:
Residential
Commercial
If Commercial, choose coverage form:
Select One
40471 (web issued policies)
44660 (manual policy)
Policy Effective Date:
Property Address 1:
Property Address 2:
City:
Zip code:
Are you insuring more than one building being constructed within 100 feet from each other at this project site:
Yes
No
If Yes, please provide total estimated completed values of all structures under construction within 100 feet and insured with us, including this one:
Construction Material:
Select One
Frame
Joisted Masonry
Non-combustible
Masonry Non-combustible
Fire Resistive
Protection Class:
Select One
1
2
3
4
5
6
7
8
9
10
Will existing structure be occupied during construction:
Yes
No
If yes, by whom?
Select One
Owner
Tenant
Other
If Other, enter description:
Square Footage:
Has the project started:
Yes
No
If Yes, Starting Date:
:
If Yes, % complete:
Is there a sales contract on the structure?
Yes
No
Estimated length of project:
Months
Years
Is structure modular:
Yes
No
Total completed value of any one structure:
$
Value of covered property at all locations:
$
Optional Coverages
Any coverage for development/subdivision fences, walls or signs:
Yes
No
If yes, enter amount:
$
Do you want Earthquake Coverage:
Yes
No
If yes, including masonry veneer:
Yes
No
Deductible:
Select One
$1,000.00
$2,500.00
$5,000.00
Other
If Other, please enter amount:
$
Is this structure located within 1000 feet of tidal water or located on a barrier island?
Yes
No
Is building being constructed on pilings?
Yes
No
If yes, enter the piling depth in feet:
Percent complete by November 1:
When will the building be capped (reach its highest point):
When will the building be fully enclosed:
What percentage of the structure is glass:
Is the glass impact resistant:
Yes
No
Modular Information
Who provides transit coverage:
How are homes transported to the job site:
Does the manufacturer put the four sides together and then the builder finish it off:
Yes
No
Does the manufacturer have a web site address:
Yes
No
If yes, enter the web address:
If no, enter detailed specifications:
Design number or plan number:
Remodeling/Rennovation Information
Amount of renovation/improvements:
$
Existing building or structure(s) amount:
$
Total complete value of all covered property:
$
General Information
Requested Coverage Amount:
$
Property State:
Type of Policy:
New Construction
Renovation Construction
Distance to fire hydrant (feet):
Distance to Responding
Fire Department (miles):
Name of Fire Dept:
Flood Coverage:
Yes
No
Is the location apartments, condominiums, or multi-unit structures:
Yes
No
If remodeler, any foundation, structural changes, or movement of load bearing walls:
Yes
No
Mortgagee Information
Mortgagee Name:
Street Address:
City:
State:
Zip code:
Phone:
Contact Person:
Fax:
Comments:
Renovation Information
Is existing structure coverage desired:
Yes
No
Age of Structure:
Is the existing structure considered historical:
Yes
No
Will the remodeling work on the existing structure being within 60 days of the effective date:
Yes
No
Provide detail of improvements to be done:
Purchase price of existing structure (excluding land value):
$
Amount of renovvations/improvements:
$
Is profit included in improvements amount:
Yes
No
Will existing structure be insured by another policy during construction?
Yes
No
Does the building have an operable sprinkler system?
Yes
No
Has the existing structure been moved or will it be moved as part of this project?
Yes
No
Date the existing structure was purchased:
Have any previous losses occurred at this location as a result of earthquake, flood, wind, fire, or vandalism?
Yes
No
If YES, Explain:
Provide a brief description of the structure to be renovvated and the condition of the existing structure.:
Commercial Information
Number of Stories:
Intended occupancy:
Square Footage:
Number of Structures:
Number of units per building:
Value per building:
Distance between buildings (ft):
Total project completed value:
$
Start and completion date of each building:
Will the structure be occupied during construction:
Yes
No
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