Property Manager Board of Directors Commercial Owner Residential Owner Commercial Tenant Residential Tenant
Condos, Townhomes & Apartments Shopping Centers Hotels & Motels Other Areas of Expertise D&O / Professional Liability


Builder's Risk Application


Name and Address of Applicant:
City: State: Zip Code:
Name and Address of Producer:
City: State: Zip Code:
Billing Contact Name and Phone Number:
Applicant is: Individual Partnership Corporation Joint Venture Other
Interest of Applicant Owner Contractor Other:
Name and Address of Mortgagee:
City: State: Zip Code:
Loss Payable Interest:
Application is for: Policy Quotation Date of Application:
Policy Term: From: To:
Frame and Joisted Masonry Construction Subject to a $5,000 Minimum Deductible
$1,000 $2,500 Other:

Description of Project:
Inspection Contact Name: and Phone Number:
Location of Project:
City: State: Zip Code:
Limits of Insurance:
a. $ At the project site
b. $ In temporary storage at any location other than the project site
c. $ While in transit
d. $ For all covered Property

City: State: Zip Code:
Has Contractor engaged in this type of project before? Yes No
if Yes, for how many years?
Contractor License Number:
Contractor Website Address:
Frame Joisted Masonry NonCombustible Masonry NonCombustible Fire Resistive/Modified Fire Resistive
Completed Value:$
Estimated time to complete project: Years Months
Total Square Footage:
Number of Floors: Above Ground? Below Ground?
Intended occupancy when completed:
Type of project: Ground-up construction Renovation/Rehabilitation - need to complete supplemental application
Is construction lift slab, tilt up or prototype? Yes No
Is project on filled land? Yes No
if "Yes", are pilings used? Yes No
Distance to operating fire hydrant: ft. Fire Department is Paid Volunteer
Will the project be equipped with working standpipes? Yes No
Public Fire Protection Class at job site:
Will temporary heating be used? Yes No
If "Yes", describe remarks:
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 the Watchman be on premises during non-working hours? Yes No
Is flood coverage desired? Yes No
Is project in a National Flood Insurance Program Special Flood Hazard area? Yes No
No Flood coverage applies to any insured location in a Flood Zone A, A1-30, AE, AH, AO,A99, AR, AR/AE, AR/AH, AR/AO,
AR/A1030, AR/A, V, V1-30, VE, VO and D as designated by Federal Emergency Management Agency's National Flood Insurance Program.
Flood means waves, tides, tidal waves, overflow of any body of water, or their spray, all of whether driven by wind or not.
If "Yes", complete the following:
Name and distance of nearest body of water to project site
Height of project site above nearest body of water:
Flood Limit $ Deductible: $
Is Earthquake Coverage desired? Yes No
Earthquake Limit: $ Deductible: $
No Earthquake coverage applies for any insured located in an Earthquake Zone 9, 10, 11, and 12 according to the modified
Mercalli Zones. No earthquake coverage applies in California, Hawaii or Alaska.
Soft Costs (Extra Expense and Rental Income):
Is Soft Cost Coverage desired? Yes No
If "Yes", check the type desired and provide the following information which is applicable to the project site:

Extra Expense

Annual or Full Dollar Amount *See note below

Construction Loan Interest $
Real Estate and Property Taxes $
Architect, Engineering and Consulting Fees $
Legal and Accounting Fees $
Builder's Risk Insurance Premium Change $
Advertising and Promotional Expenses $
Total Extra Expense Values: $
Rental Income:
Total Rental Income Values $
Limit of Insurance Requested for:
Extra Expense $
Rental Income $
*Show full amount of exposure for the entire job. Limit of Insurance may be less.

Forms by Dime Store Designs