Insured Information
Insured Name (as it should appear on the policy):
*
Mailing Address:
*
Location of Risk:
*
Proposed Effective Date
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Mortgagee Information
Mortgagee - Name
if applicable
Mortgagee - Address
if applicable
Loan #
if applicable
Back
Next
Insurance History
Previous Insurer: Indicate premium and losses for the past three years. Describe all losses. If none or no prior, please indicate.
Rows
Year
Company
Policy #
Premium
Losses Paid
Losses Reserved
Description
1
2
3
During the past three years has any company cancelled, declined, or refused similar insurance:
*
Yes
No
If yes, explain:
Back
Next
Property & Building Values
Rows
Exposure
Existing Value
Cost of Renovation
Completed Value
Deductible
Reno or Ground Up?
Name of GC
Address of GC
Does GC carry separate GL coverage?
Building #1
Renovation
Ground Up
Yes
No
N/A
Building #2
Renovation
Ground Up
Yes
No
N/A
Other
Renovation
Ground Up
Yes
No
N/A
Construction Type (check all that apply):
*
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Building Details
Square Footage:
*
Year Built:
*
Number of Stories:
*
Protective Devices
Fire Alarm:
*
Yes
No
If yes, type:
Sprinklered:
*
Yes
No
Other Protective Devices
Property Status
Is Property? (check all that apply) *see additional questions
*
Vacant
New Construction
Renovation
Vacant Condo*
New Purchase*
Residential
Commercial
Boarded
Locked
Fenced
Alarmed
If new purchase and previously vacant - vacant since?
If a residential dwelling, does any part of the dwelling consist of a "mobile home" or "modular home"?
Yes
No
Renovation / Builders Risk
Intended use of building(s)
*
Describe extent of renovation, if any
Does the building amount listed above include renovations or the entire structure?
*
Renovations Only
Entire Structure
Is the insured a GC or a construction company?
*
Yes
No
Back
Next
Requested Coverages
Plans/Budget
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Applicant Signature and Confirmation
Applicant's Name
Applicant's Email
Date
-
Month
-
Day
Year
Date
Applicant's Signature
Agent Signature and Confirmation
Agent Name
*
Agent Email
*
Agency Name
*
Agency Phone Number
*
Date
*
-
Month
-
Day
Year
Date
Agent Signature
*
Applicants Signature
Continue
Continue
Should be Empty: