Builder's Risk Program

CLIENT INFORMATION:
Client Name:
Mailing Address:
Town:
State:
ZIP:
Client Description:	Homeowner Investor Contractor
Do you have insurance now?	Yes No
If Yes, when does it expire?
If No, please choose a reason:	New Aquisition Prior Policy Cancelled Prior Policy Non-Renewed
PROJECT DESCRIPTION:
Project Description:	New Construction / Single Family Dwelling New Construction / Muti-Unit Habitational New Construction / Commercial Building New Construction / Multi-Unit Commercial New Construction / Addition Remodel / Single Family Dwelling Remodel / Multi-Unit Habitational Remodel / Commercial Building Remodel / Multi-Unit Commercial
Intended Disposition of Property:	Primary Residence Rental Property Resale
Date of Property Aquisition:
Property Address:
Are you using a General Contractor (GC)?	Yes N/A No
Do you or your GC have at least 2 years experience?	Yes No
Name of GC (If Applicable)
Is your GC insured?	Yes N/A No
Estimated Length of Project (Months):
Anticipated Start Date of Project:
COVERAGES:
Purchase Price of Property (If Applicable):	(A)
Value of Land/Lot:
Cost of Improvements (Material & Labor):	(B)
Expected Profit (If Applicable):	(C)
Value of Finished Structure:	(A) + (B) + (C)
Do you wish to insure the existing structure?	Yes No
UNDERWRITING INFORMATION:
Square Footage of Existing Structure (If Applicable):
Square Footage of Addition (If Applicable):
Square Footage of New Structure (If Applicable):
Size of Lot (Approx.)
Are you within 1,000 feet of tidal waters?	Yes No
Age of Existing Structure (If Applicable):
Is this a new purchase?	Yes No
Has Construction Begun?	Yes No
Construction Type of Existing Structure (If Applicable):	Frame Brick Frame w/Stucco Cement Block w/Wood Roof Cement Block w/Steel Roof Fire Resistive
Distance of Closest Fire Hydrant:	1,000 Feet or Less Over 1,000 Feet No Fire Hydrant
Distance of Closest Fire Station:	5 Miles or Less Over 5 Miles
Foundation Type:	Full Basement Crawl Space Slab Piers or Pilings
Is this a modular home or prefab construction?	Yes No
Age of Existing Roof (If Applicable):
Last Heating Update:		Partial               Complete
Last Electric Update:		Partial               Complete
Last Plumbing Update:		Partial               Complete
Type of Heat:	Natural Gas Oil Electric Propane
If Oil Heat, Answer:	NA In Basement In Ground Above Ground On Slab Above Ground, No Slab
Description of Improvements to Property:
Are you doing any structural work?	Yes No
Have You Had Any Claims in 5 Years?	Yes No
If so, please list date and details regarding your claim including type of claim and amount paid.
Contact's Phone Number (Include Area Code):
Contact's Fax Number (Include Area Code):
Contact's E-Mail Address: