Renovation / Construction Insurance Request Form
Less emails, more efficiency! Please complete the form below to obtain insurance coverage for a renovation or construction project. Once this is complete, we'll shop our markets for accurate coverage & best cost. Thank you, Philip Miles / CA Lic #0K93165, AZ Lic# 17963684
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if you are an insurance agent, please let me know :)
What date would you like coverage to begin?
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Month
-
Day
Year
Date
What is the name/entity name to be insured?
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The applicant is a(n):
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Induvidual
LLC
INC
Other
Mailing address for the policy?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is Signing DocuSign?
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone
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Please enter a valid phone number.
Date of Birth
*
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Month
-
Day
Year
Date
Project Information
What best describes the work to be done on this project?
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Remodel - Remodeling of interior finishes; exterior painting; replacement of interior fixtures, cabinets, flooring, etc. No structural changes. *Premium is Pro-Rata*
Remodel/Minor Structural - Remodel work as listed above and minor changes to exterior (doors, windows, skylights, etc.). Roof replacement, ground floor additions and all non-structural changes such as HVAC, plumbing and electrical. *Premium is Fully Earned, No Refunds*
Restructuring - Repair, replace, remove load bearing walls. Adding additional stories, adding stairways or elevators. Structural retrofitting or foundation work such as underpinning and/or dewatering. (if this is your selection, please upload project plans below) *Premium is Fully Earned, No Refunds*
New build- This includes new from grading, foundation, and structure
Project Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there more than one building on property within 100 ft of the main structure being built? If so please describe
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What is the labor budget (aka soft cost) for this project?
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What is the materials budget (aka hard cost) for this project?
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How long will this project be active?
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6 Months or Less
9 Months
1 Year
Longer than 1 Year
Will there be any work done on the foundation of the property?
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Yes
No
What is your builders name?
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Does your builder/remodeler/owner/ GC have at least 2 years experience.
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Number of structures/ projects Builder has completed for the next 12 months?
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Has the builder/remodeler and/or structure had any single losses over $10,000 in the last 3 years (include insured/uninsured losses in description below)
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What is the construction material (frame, Log, masonry, etc)
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Is the property within 5 miles of a fire station?
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Number of stories
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Intended occupancy (single family, duplex, etc)
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Square footage of completed project
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Has the project started? If so what date and % complete
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Any other specific losses you would like to cover against during the policy period?
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Upload docs like Scope of Work, Appraisal, GC Information, Insurance Requirements, Pans/Designs, etc.
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Payment & Notes
How will this policy likely be paid?
*
Directly to the entity or individual with bank account or credit card
Closing cost with escrow
Any special notes you'd like to add?
Submit to Philip's Team
Should be Empty: