Builders risk Application
Broker Name
*
First Name
Last Name
Broker Email
*
example@example.com
Insured Name
Mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Project
*
Project Location address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Project lattitude
Project longitude
Project description
Please provide a quick summary
Name of General Contractor
General Contractor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start date
 -
Month
 -
Day
Year
Date
Finish date
 -
Month
 -
Day
Year
Date
Days on risk
Flood and Quake
Including Flood
Excluding Flood
Including Earthquake
Excluding Earthquake
Total Project Value
Hard Costs
Number
Soft Costs
Loss or Rents
Existing property coverage
Total
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Sub limits
Wind/Hail/Tornado
Named Windstorm
Wildfire
Interior Water Intrusion
Water Damage
Theft/Vandalism/Malicious
All other perils
Flood
Earthquake
Deductibles
Wind/Hail/Tornado
Named Windstorm
Wildfire
Interior Water Intrusion
Water Damage
Theft/Vandalism/malicious
All other perils
Flood
Earthquake
Premium
Premium
Hard cost annual rate
Soft cost annual rate
Loss of rents annual rate
Existing coverage annual rate
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Construction details
Number of levels below ground
Number of levels above ground
Foundation
Building material
Please Select
Frame
Frame Podium
Joisted masonary
Noncombustible
Masonry noncombustible
Modified or Semi fire resistive
Fire resistive
Intended usage
Wood Frame additional info
Please check default answers below
Litmus risk management endorsement will be part of this agreement
Please Select
Yes
No
Contractors Builders risk loss record is clean past 5 years. if not please forward loss info
Please Select
Yes
No
Structure has more than two levels of basements
Please Select
Yes
No
Structure has no more than two levels of basements
Please Select
Yes
No
Recommendations in the Geo tech report being adhered to
Please Select
Yes
No
Project type
Please check default answers
Project type
New build
Renovation
If Renovation - cover for existing building
Please Select
Yes
No
Not applic
If Renovation - age of building (years)
If Renovation - value of existing building
If Renovation - type
Please Select
Structural
Non - Structural
Not applic
Site protections
Please check default answers
Site fenced
Please Select
Yes
No
Site lit
Please Select
Yes
No
Watchman
Please Select
Yes
No
Central station alarm
Please Select
Yes
No
Monitored CCTV
Please Select
Yes
No
Further details
Fire Protection details
Distance to nearest fire station (Miles)
Number of hydrants within 1000ft
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Extensions of cover
Contract Work
Damage to Existing property
Debris Removal
Coverage B
Coverage C
Inland transit
Offsite Temp storage
Extra expense
Architects, Engineers & Professional Fees
Trees, Shrubs, Plants and Landscaping
Plans, Blueprints and other contract documents
Ingress/Egress
Civil or Military Authority Extension
Fire Brigade Charges and Extinguishing expenses
Emergency Property protection expense
Temporary Works
Rewards
Tower Crane and/or Material
Green Building
loss of rental income
Loss of gross earnings
Soft costs/ additional expenses
Terrorism
Contaminants or Pollutants
Claim preparation costs
Fungus and Mold
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Documents to upload
Statement of values
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Gaant chart / timescale
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Site Plan
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Risk Meter report
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Geotech report
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Fire and water damage mitigation plans
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Other useful info
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