Ventura Builders Risk and Wrap Submission

General Information
Project Manager Name

First NameLast Name
Project Manager Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Project Manager Email
example@example.com
Name of Insured
Address of Insured
The insured is:
Interest of insured:
Name of Project
Address of Project

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Jobsite Loss Control Name

First NameLast Name
Jobsite Loss Control Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Construction Period Start Date

MonthDayYear
Date
Construction Period End Date

MonthDayYear
Date

Contractor Information

Part 3 of 10
Name of Principal Contractor
Address of Contractor
Project Participants:
a) Owner:
b) General/Project Manager:
C) Prime Architect:
d) Engineering Firm:
e) Geotech Engineer:
Does the Principal Contractor have a written safety program in place?
Does the Principal Contractor employ a designated job site risk manager?
Does the Principal Contractor obtain evidence of insurance from all sub-contractors
Does the Principal Contractor pre-qualify all sub-contractors?
Blank Field Type a label

Construction Information

Part 4 of 10
Construction Materials
Framework:
Exterior Walls:
Roof Structure:
Floor Structure:
Height of structure:  Type a label    Storeys:
Feet or Metres:     Feet    Metres
Below Grade:
Above Grade: Type a label
Total Area:
Is an Exterior Insulation and Finish Systems (EIFS) used?
If yes, does the EIFS assembly include expanded polystyrene insulation (EPS) or other combustible materials?

Protection Information

Part 5 of 10
Fire Protection
Distance to the Nearest Fire Department:
Name of City or Town Providing Protection:
Number of Hydrants (operational):
Please describe all Private Fire Protection:
Will the project be sprinklered?
If yes, at which time will the sprinkler system be in operation?
Security Protection
Is the site fenced?  Yes. Height/Type:    Type a label
Watchman service?    Yes   No    Hours/Rounds:   Type a label
Alarm:   Intrusion   Fire/Smoke      Alarm sounds to:  Type a label
Video Surveillance: Yes.  Type:

Builder's Risk Information

Part 7 of 10
Testing
Who will perform testing operation?
Will testing be performed?
Please describe all operations for testing/commissioning:
Will the project involve the installation of any used equipment?
Testing Period Start

MonthDayYear
Date
Testing Period End

MonthDayYear
Date
Flood Exposure
Name of nearest body of water
Distance of nearest body of water
Describe any past flood history at the site
Height of project above maximum flood stage:
Please describe the exposure during and after excavation from surface water and ground water:
Please describe the precautions to be taken to prevent damage from flood:
What is being done to prevent run-off damage:
Site Risks
Please detail the exposures from winter heating conditions (type of heaters):
Please detail the exposures from explosion:
Please Describe Hot Works and Approximate Cost of Hot Works:
Off-Site Risks
Will any construction material, plant or equipment be stored off-site at non-owned locations?
If yes, please provide all public and private fire and theft protections:

Wrap Up Liability Information

Part 8 of 10
Existing Structure
Does the project attach to or communicate with an existing structure?
If yes, manner in which structures will connect or communicate:
Will the existing structure be occupied during the construction period?
If yes, please provide details including current occupancy:
What operation and income is likely to be affected if the existing structure is damaged:
Please detail the exposures to utilities, including relocation thereof (both below and above grade):
Please provide details of the Loss Control Program to be implemented to protect others from operations (i.e. traffic control, preconstruction surveys, vibration monitoring, preconstruction location of utilities and notification to others of interruption thereof, etc.):

Broker Information

Part 9 of 10
Name of Brokerage: HUB International
Brokerage Address: 9-1661 Portage Avenue, Winnipeg, MB
Name of Broker Contact: Mark James
Is this account NEW to your office? No

Declaration

Part 10 of 10
I/We hereby declare that the statements and particulars contained in this application are true and that I/we have not suppressed or mis-stated any material facts and I/we agree that should a policy be issued then this application shall be the basis of the contract with Underwriters.
Signature
Todays Date

MonthDayYear
Date
NOTE: Underwriters will rely upon complete responses given in this Application Form and any Supplementary Application Form in deciding whether or not to insure this risk and if so at what premium, terms and conditions. Underwriters regard every response to be material to their decisions. Failing to answer or answering any question below incorrectly could invalidate any policy of insurance written by Underwriters for this risk.

We have a professional duty of confidentiality and are committed to holding personal information in strict confidence. The information provided to us will only be disclosed where required by law to do so or required to do so in conducting negotiations with third parties, such as insurance companies, on your behalf. We will further safeguard the security of such information in a manner appropriate to sensitivity of that information.

General Information