Builders Risk Application
Your Name
*
First Name
Last Name
Your Date of birth
*
-
Month
-
Day
Year
DOB
Spouse Name (if single - leave blank)
First Name
Last Name
Spouse Date of birth
-
Month
-
Day
Year
DOB
Please enter the legal name under which the property is registered, such as LLC, Corp, or Trust. (if applicable).
What’s your Phone Number?
*
Please enter a valid phone number.
Format: (000) 000-0000.
What’s your email address?
*
example@example.com
What’s the Location address? (Property to be insured)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Whats your mailing address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Coverage(s) Desired:
*
Property only
Property and personal liability
How long would you like the policy term to be?
*
3 months
6 months
9 months
Annual
Does this entity engage in any business interests other than residential real estate?
*
Yes
No
Is the applicant a contractor, developer or in the business of flipping properties?
*
Yes
No
Is the building 100% vacant?
*
Yes
No
Provide a description of work being done:
*
What is the total cost of the Project/renovation?
*
Are the planned renovations structural (load bearing)?
*
Yes
No
Are you hiring subcontractors to perform work?
*
yes
No
Are certificates of insurance naming the applicant as an additional insured required for all subcontractors?
*
yes
No
Estimated start date:
*
-
Month
-
Day
Year
Date
Estimated completion date:
*
-
Month
-
Day
Year
Date
Liability limit requested:
*
$500,000
$1 million (Standered)
Building Limit coverage needed?
*
Building Construction:
*
Frame
Modified fire resistive
Joisted masonry
Fire resistive
Noncombustible
Log
Masonry noncombustible
What type of plumbing is or will be in the building?
PVC or PEX
Copper
Galvanized
Iron
Lead
Other
What type of roof is on the building?
Flat
Metal
Wood shake
Tile
Shingle
Slate
When was the building / lot purchased ?
*
Purchase price:
*
Has insurance coverage been canceled or nonrenewed in the past three years?
*
yes
No
Please list the length of and reason for the lapse/cancellation or nonrenewal:
*
Is the building currently damaged by fire or otherwise?
*
Yes
No
Is the building scheduled for demolition during or after the policy term (except incidental non-load bearing interior work)?
*
Yes
No
Is the building locked and secured from unauthorized entry?
*
Yes
No
Do you have a swimming pool?
*
Yes
No
Is there a trampoline at this location?
*
Yes
No
Did you file any home or property claim within the past 5 years?
*
Yes
No
Please advise the details of the claims, including what happened, the date, and the amount of the loss.
*
Would you like for us to quote you any additional insurance quotes
Flood Insurance
Valuable Items (jewelry, artwork, etc.)
Commercial Insurance
Workers Comp Insurance
Anything else you would want the agent to know regarding the home?
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