Builders Risk Application Quote Form
Policy effective date
/
Month
/
Day
Year
Date
Insured name
Type of entity
Please Select
Individual
Partnership
Trust
S-Corp
C-Corp
LLC
Non-profit
Contact name
First Name
Last Name
Contact phone number
Please enter a valid phone number.
Email address
example@example.com
Mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of named insured
Owner/contractor
Owner
Contractor
Is the builder's name different than the named insured?
Yes
No
Builders Name
Builders address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Builders Phone number
Please enter a valid phone number.
Does builder/remodeler/owner/GC have at least 2 years experience?
Yes
No
Number of structures/projects projected for the next 12 months
1-2
3-50
Other
Has the builder/remodeler and/or structure itself had any single loss or damage over $10,000in the last 3 years (Include insured/uninsured losses/damages)
Yes
No
Type of project
New Construction
Remodeling/Renovation excluding coverage for the existing structure
Remodeling/Renovation including coverage for the existing structure
Installation
Type of property
Residential (1-4 single family dwelling/units)
Commercial
Construction Material
Frame - exterior walls constructed of wood or other combustible materials such as brick veneer, stone veneer, wood and stucco on wood.
Joisted Masonry - exterior walls constructed of masonry materials such as brick, concrete, block, stone or similar materials and the floors and roof are of wood construction.
Non-Combustible - exterior walls, floors and roof constructed of metal, gypsum or other non-combustible materials.
Masonry Non-Combustible - exterior walls, floors and roof constructed of masonry or fire resistive materials with fire resistance rating of not less than 1 hour.
Fire Resistive - exterior walls, floors and roof constructed of masonry or fire resistive materials with a fire resistance rating of not less than 2 hours.
3D Printed - construction 3D printing is a method for manufacturing construction elements or entire buildings by means of a 3D printer printing concrete, polymer, metal, or other materials, layer-by-layer.
Has the project started yet?
Yes
No
If "No", will renovations begin within 60 days of the policy effective date
Yes
No
Expected completion date of project
-
Month
-
Day
Year
Date
Description of work to be performed
Total completed value of property being installed
Square footage of existing structure INCLUDES basement
Square footage of structure after completion of construction
Year built (existing structure)
Number of stories
Habitational Type
Owner occupied units
Rental Units
Both
Any previous damage at this location as a result of quake, flood, wind, fire or vandalism (include insured and uninsured damages)
No
Yes
Scope of work
Remodel - Remodeling of interior finishes; exterior painting; replacement of interior fixtures,
Remodel/Minor Structural - Remodel work as listed above and minor changes to exterior doors
Restructuring - Repair, replace, remove load bearing walls. Adding additional stories, adding
Is the structure modular
Yes
No
Amount of renovation/improvements
Do you want to insure the existing structure? (Actual Cash Value only)
No
Yes
Existing building(s) or structure(s) amount
Actual Cash Value
Will the existing structure be insured by another policy during construction
Yes
No
Is the existing structure listed on any historical registry or subject to a historical society regulation
Yes
No
Has the existing structure been moved or will it be moved as part of this project
Yes
No
Date existing structure was purchased
-
Month
-
Day
Year
Date
What is the condition of the existing structure
Poor Condition - Uninhabitable, siding/shingles missing, dilapidated, overgrown landscaping, fire damaged, flooded, vandalized or stripped of copper. Major repairs needed
Fair Condition - Lacks maintenance and/or minor repairs are needed to bring into average condition.
Good Condition - Well maintained and little/no evidence of deferred maintenance. Minimal repairs can be quickly and affordably resolved and are only cosmetic in nature.
Provide a brief description of the structure to be renovated
Please upload any plans that you have for the project
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If engineering is required, please provide the name of the engineer or engineering firm that approved the project
Is this property currently insured?
Please Select
Yes
No
Current insurance carrier
Current insurance expiration date
/
Month
/
Day
Year
Date
Any claims in the last 3 years
No
Yes
If yes, please upload '3 year loss runs'
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Can be obtained from your current insurance agent/broker/insurance company
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of
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