Builders Risk Supplemental Application
Date:
-
Month
-
Day
Year
Date Picker Icon
Name of Insured:
Address of Insured:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Producer:
Address of Producer:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
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
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
Date Picker Icon
Signature:
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