Form

Date:

- Month - Day Year

Name of Insured:

Address of Insured:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Name of Producer:

Address of Producer:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Applicant is:

Individual Partnership Corporation Joint Venture

Interest of applicant:

Owner Contractor

Name of Mortgagee:

Address of Mortgagee:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

	From:	To:
POLICY TERM:

Deductible:

$2,500 $5,000 $10,000

Location of project:

Description of project:

Is this a renovation?

Yes No

Describe structural work to be completed:

Contractor Name:

Contractor Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Has the Contractor completed this type of project before?

Yes No

How many years in business?

Inspection contact name and phone number:

LIMITS OF INSURANCE:

1. At the project site

2. In temporary storage at any other location

3. While in transit

4. Other

5. For all covered property

Flood limit requested:

Deductible:

Flood Zone:

Earthquake limit requested:

Deductible:

Soft Costs (Extra Expense and Rental Income) Is Soft Cost Coverage desired?

Yes No

If 'yes', provide the following information:

Extra Expense:

	Annual or Full Dollar Amount
Construction Loan Interest
Real Estate and Property Taxes
Architect, Engineering and Consultant Fees
Legal and Accounting Fees
Builder's Risk Insurance Premium Charge
Advertising and Promotional Expenses
Other - describe and dollar amount
Total Extra Expense Values

Rental Income:

	Annual or Full Dollar Amount
Total Rental Income Values

Limit of Insurance Requested for:

	Annual or Full Dollar Amount
Extra Expense:
Rental Income:

Construction:

Frame Joisted Masonry Non-Combustible Masonry Non-Combustible Modified Fire Resistive/Fire Resistive

Completed Value:

Total Square Footage:

Number of Floors:

Intended Occupancy when completed:

Protection:

Distance to operating fire hydrant:

Fire Department:

Paid Volunteer

Will the project be equipped with working standpipes?

Yes No

Public fire protection at the job site:

Will temporary heating be used?

Yes No

Will the project site be fenced?

Yes No

Will the project site be locked?

Yes No

Will the project site be lighted?

Yes No

Will there be a watchman on premises during non-working hours?

Yes No

Date

- Month - Day Year

Signature:

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Builders Risk Supplemental Application