New Client Habitational Property / GL Insurance Form

Property Coverage Information
Is the owner / applicant and Corporation, LLC, Entity or Individual?*

Corporation, LLC, Partnership, Non-Profit, Other EntityIndividual
Business / Applicant Name*
Business Entity Type*
Federal EIN #*
DBA (If Applicable)
Year Started*
Entity Contact Name*
Entity Contact Email*
Contact Phone Number
Owner's Name*
Owner's Email*
Phone Number
Applicant Location / Physical Address*
Is the Business Mailing Address the same as the Physical Address?*

YesNo
Mailing Address
Key Personnel

Person responsible for the business insurance.
Business Insurance Person*
Email*
Phone Number*
Title
Add Key Personnel
Full Name
Email
Phone Number
Title
Add Key Personnel
Full Name
Email
Phone Number
Title
Add Key Personnel
Full Name
Email
Phone Number
Title
Add Key Personnel
Full Name
Email
Phone Number
Title
Brief Description of Operations:
Please provide a description of occupancy.*
Property Coverage Information
Is location 1 address the same as the applicant physical address?*

YesNo
Location #1*
Year Built*
Occupancy Code (ATC Codes)*
Occupancy Description*
Construction Code (ISO)*
Building Upgrade Information:
Plumbing Upgrade*
Electrical Upgrade*
HVAC Upgrade*
Roof*
Number of Stories*
Number of Buildings*
Square Footage*
Sprinklered*

YesNo
Statement of Values:
Building Value*
Contents Value*
BI / Rental Income*
Total Insured Value
Windstorm Insurance Information (if required)*

YesNo
Please answer the following questions.
Basement*

0 = Unknown1 = No Basement2 = Basement w/ Flood Protection3 = Basement w/out Flood Protection4 = Basement w/Unknown Flood Protection
Frame-Foundation Connection*

0 = Unknown1 = Bolted2 = Unbolted
Construction Quality*

0 = Unknown1 = Obvious signs of deterioration or distress2 = Fortified for Existing Homes, Bronze, Option 13 = Fortified for Existing Homes, Bronze, Option 24 = Fortified for Existing Homes, Silver, Option 15 = Fortified for Existing Homes, Silver, Option 26 = Fortified for Existing Homes, Gold, Option 17 = Fortified for Existing Homes, Gold, Option 28 = Fortified for Safer Living - [Post 2001]9 = Certified design & construction
Shape of Roof*

0 = Unknown1 = Flat roof with parapets2 = Flat roof without parapets3 = Hip roof with slope less than or equal to 6:12 (26.5 degrees)4 = Hip roof with slope greater than 6:12 (26.5 degrees)5 = Gable roof with slope less than or equal to 6:12 (26.5 degrees)6 = Gable roof with slope greater than 6:12 (26.5 degrees)7 = Braced gable roof with slope less than or equal to 6:12 (26.5 degrees)8 = Braced gable roof with slope greater than 6:12 (26.5 degrees)
Roof Covering*

0 = Unknown1 = Metal sheathing with exposed fasteners2 = Metal sheathing with concealed fasteners3 = Built-up roof or single-ply membrane roof with the presence of gutters4 = Built-up roof or single-ply membrane roof without the presence of gutters5 = Concrete/Clay Tiles6 = Wood Shakes7 = Normal Shingle (55mph)8 = Normal Shingle (55mph) with Secondary Water Resistance9 = Shingle rated for high wind speeds (110mph)10 = Shingle rated for high wind speeds (110mph) with Secondary Water Resistance
Roof Strapped*

0 = Unknown1 = Toe nailing/No anchorage2 = Clips3 = Single wraps4 = Double wraps5 = Structural
Roof Age / Condition*

0 = Unknown1 = 0-5 years2 = 6-10 years3 = 11 years or more4 = Obvious signs of deterioration and distress
Exterior Cladding*

0 = Unknown1 = Brick Veneer2 = Methal Sheathing3 = Wood4 = EIFS / Stucco5 = Impact Rated Glazing6 = Glazing not designed for impact with gravel rooftop within 1000ft7 = Glazing not designed for impact without gravel rooftop within 1000ft8 = Vinyl Siding
Roof Sheathing Attachment*

0 = Unknown1 = Batten Decking / Skipped Sheathing2 = 6d Nails - Any nail schedule3 = 8d Nails - Minimum nail schedule4 = 8d Nails - High wind nail schedule5 = 10d Nails - High wind nail schedule6 = Dimensional lumber / Tongue & groove decking with a minimum of 2 nails per board
Commercial Appurtenant Structures*

0 = Unknown1 = Large Signs2 = Extensive Ornamentation
Residential Appurtenant Structures*

0 = Unknown1 = None2 = Fences / Carport3 = Screen enclosure / Lanai (more than 15% of Bldg value)4 = Screen enclosure / Lanai (less than 15% of Bldg value)
Roof Equipment Hurricane Bracing*

0 = Unknown1 = Properly installed with adequate anchorage2 = Obvious signs of deficiencies in the installation
Ground Level Equipment*

0 = Unknown1 = None2 = Generally Protected (the systems are located 5 ft above ground and/or have waterproof coverings)3 = Generally Unprotected (the systems are not elevated or do not have coverings)
Resistance - Windows*

0 = Unknown1 = All openings designed for pressure & large missiles (including doors)2 = All openings designed for pressure & medium missiles (including doors)3 = All openings designed for pressure & small missiles (including doors)4 = All glazed openings designed for pressure & large missiles (doors not designed for pressure/impact)5 = All glazed openings designed for pressure & medium missiles (doors not designed for pressure/impact)6 = All glazed openings designed for pressure & small missiles (doors not designed for pressure/impact)7 = All glazed openings covered with plywood/oriented strand board (OSB) (doors not designed for pressure/impact)8 = At least one glazed exterior opening does not have wind-borne debris protection (doors not designed for pressure/impact)9 = No exterior openings (glazed or non-glazed) have wind-borne debris protection10 = All glazed openings designed for pressure & large missiles & doors designed for pressure only11 = All glazed openings designed for pressure & medium missiles & doors designed for pressure only12 = All glazed openings designed for pressure & small missiles & doors designed for pressure only13 = All glazed openings covered with plywood/OSB & doors designed for pressure & missile impact14 = All glazed openings covered with plywood/OSB & doors designed for pressure only15 = No glazed openings with windborne debris protection but doors designed for pressure & missile impact16 = No glazed openings with windborne debris protection but doors designed for pressure only
Earthquake Insurance Information (if required)*

YesNo
Please answer the following questions.
Shape Configuration*

1 = Regular2 = Irregular
Soft Story*

0 = Unknown1 = No2 = Yes
Setbacks & Overhangs*

0 = Unknown1 = No2 = Yes
Cladding*

0 = Unknown1 = Glass2 = Precast Concrete3 = Unreinforced Masonry
Short Column Condition*

0 = Unknown1 = No2 = Yes
Mechanical & Electrical Equipment*

0 = Unknown1 = Generally Well - Braced2 = Somewhat Braced3 = Generally UnBraced
Construction Quality*

0 = Unknown1 = Good2 = Average3 = Poor
Duress*

0 = Unknown1 = No signs2 = Few signs3 = Obvious signs
Pounding*

0 = Unknown1 = No - bldg is > 3 in. per story away from adjacent2 = Yes - bldg is < 3 in. per story away from adjacent
Engineered Foundation*

0 = Unknown1 = Yes2 = No
Crippled Walls*

1 = No Cripple Walls2 = Braced Cripple Walls3 = Unbraced Cripple Walls
Frame Bolded*

0 = Unknown1 = Bolted2 = Unbolted
Anchoring*

0 = Unknown1 = Properly Anchored2 = Not Properly Anchored
URM Retrofit*

0 = Unknown1 = Yes2 = No
Structural Upgrade*

0 = Unknown1 = Yes2 = No
Base Isolation*

0 = Unknown1 = Yes2 = No
Sprinkler Type*

0 = Unknown1 = Wet2 = Dry
Risk Management & Safety: Best Practices Assessment
Does your company have a dedicated Safety Director ?*

YesNo
Does your company have a written Safety policy?*

YesNo
Do you have an accident investigation process?*

YesNo
Do you maintain an accident register?*

YesNo
Does your company have a dedicated HR Director employed?*

YesNo
How often are Safety Meetings held?
Secure File Upload
Please upload the following Documents:
- Contractual Insurance Requirements
- Current Certificate of Insurance including any endorsements needed for contractual purposes.
- Builders Risk Policy - Current
- Builders Risk Loss History
- Copies of current policies (all lines).
Accepted file types: .jpg, .pdf, .png, .xls, xlsx

Max file size: 1 GB.
Cancelof
Please verify that you are human*
What date do you need this by?

MonthDayYear
T. Hudson Risk Advisor
T. Hudson Risk Advisor EMAIL
Should be Empty:

Property Coverage Information

Property Coverage Information

Risk Management & Safety: Best Practices Assessment

Secure File Upload