Builder's Risk Insurance Quote Request
Business Details:
Legal name
*
Operating name (if any)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main phone
*
Please enter a valid phone number.
Main email
*
example@example.com
Website
Legal entity:
*
Sole proprietorship
Partnership/Joint venture
Incorporation
Other
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Contact Person Details:
Contact person's full name
*
First Name
Last Name
Contact person's phone no.
*
Please enter a valid phone number.
Contact person's email
*
example@example.com
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Insurance Details:
Current insurance company name (if applicable)
Current insurance policy number (if applicable)
Effective/renewal date
*
-
Month
-
Day
Year
If renewal was not being offered, please explain.
Describe all claims, including any outstanding, and fees for the last five years including any accidents, facts, circumstances or allegations which may give rise to a claim:
What action has been taken to eliminate future accidents?
Has any similar insurance applied for or carried by the Applicant been declined or cancelled by any insurer within the last three years?
*
Yes
No
If “Yes”, please provide full details.
*
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Business Risk Assessment:
Property Owner:
*
Property Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Policy:
*
New Construction
Remodel (please complete Renovation Information section at the end)
Expected Start Date:
*
-
Month
-
Day
Year
Date
Estimated length of project:
*
Description of Construction:
*
*
Value
Sq. Ft
a) Existing Structure
b) Completed Structure
Construction Material:
*
Frame
Joisted Masonry
Masonry Non-Combustible
Non-Combustible
Has the Project Started?
*
Yes
No
Date started
*
-
Month
-
Day
Year
Date
Percent completed
*
Is existing structure coverage desired?
*
Yes
No
Any coverage for development/subdivision fences, walls or signs?
*
Yes
No
If “Yes”, enter coverage amount
*
Do you have any Additional Insureds?
*
Yes
No
Is the Builders name different than the Insured's Name?
*
Yes
No
If “Yes”, provide builder's name
*
Is this structure modular?
*
Yes
No
Is the location apartments, condominiums or multi-unit structure(s) ?
*
Yes
No
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Mortgagee/Loss Payee:
Lender's Name
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Builder/General Contractor Questionnaire:
General Contractor
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the Builder/Remodeler have at least two (2) years experience?
*
Yes
No
Business Description:
Homebuilder
General Contractor
Remodeler
If remodeler, any foundation, structural changes or movement of load bearing walls?
*
Yes
No
Is the contractor insuring any other buildings within 100 ft of this structure?
*
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
Loss Experience for the past three (3) years: (Enter 0 if none)
*
Indicated cause of loss for any claim over $5,000: (Enter N/A if none)
*
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Renovation Information:
*** You selected "Remodel" for the type of policy, please complete the following section:
Age of Dwelling:
*
Is structure considered historical?
*
Yes
No
Is remodeling work on the existing structure to begin within 60 days of the policy effective date?
*
Yes
No
When was the heating system last updated?
*
When was the electrical system last updated?
*
Purchase price of shell $
*
Amount of renovation/improvements $
*
Is profit included in renovation/improvements amount?
*
Yes
No
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By submitting the above-mentioned information, the applicant declares that all statements made in the questionnaire and the information contained in documents submitted with it are true. Submitting of this document does not bind the applicant to complete the insurance, but it is agreed that the questionnaire shall be the basis of the contract, should a policy be issued.
Submit
Should be Empty: