LifeStore Insurance_Builders Risk Questionnaire

SCOPE OF WORK - INSURANCE

Date:

Date

Named Insured:

Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Project Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is builders’ risk in name of owner or builder:

Builder:

Builder Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone:

Please enter a valid phone number.

Email Address:

example@example.com

Website:

Years of Experience:

Builder have any losses - Advise:

Governing Municipality/Fire Department:

Fire Hydrant within 1,000 feet:

Permit Required:

Estimated Construction Start (Date):

Project Duration (Date):

Has project started?

% of project completed ‐ what completed?

Homeowner and/or Property Owner Name:

Homeowner and/or Property Owner Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Homeowner and/or Property Owner Phone:

Please enter a valid phone number.

Mortgagee:

Mortgagee Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mortgagee Phone:

Please enter a valid phone number.

PROJECT SCOPE - INSURANCE BUILDERS RISK

Construction Type - is it frame, brick, masonry:

Roof Type:

Square feet of construction area:

Total square feet of dwelling or commercial building:

Replacement Cost of structure:

Deductible Requested:

# of Stories:

Renovation cost:

Renovations and or additions - advise what is being done:

Builders Risk to insure just renovations or renovations and existing structure?

Existing Structure value?

Any load bearing wall being moved or added?

Will property be occupied during construction?

Fire Extinguisher at premises?

Is job site nonsmoking?

Are all combustible materials stored in safe location?

How is site secured?

Are hot work procedures in place?

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