Builders Risk- Monthly Reporting - Application

Application Date: Agency: Producer: Effective Date:

APPLICANT INFORMATION

Business Type IndividualApplicant Name: Mailing Address: Partnership

Corporation

LLCLocation Address (if different from Mailing Address or if Mailing Address is PO Box):

Contact Name: Interest of Applicant: Owner

Contact Phone:

Contractor Other

RISK INFORMATION

Project Street Address: City:

State:Zip Code:

1-4 5-6

FR JM

New Construction

7-8

NC MNC

Protection Class:

Construction:

Type of Project:

Project Description:

LOSS PAYEE INFORMATION

Loss Payee Name: Address:

POLICY DEDUCTIBLESAOP Deductible ($2,500 minimum required): $2,500

1% 2% 5% Flat $

5%

Wind Deductible Earthquake

Please provide estimates for projected new starts for the next 12 months:

Construction Limit for any one building:

Catastrophe Limit for any one occurrence:

Number of homes:

Distance to coastal water:

Average completed value per home:

Average square footage:

Average duration per home: (mos.)

Average # of homes in progress any one time:

Number of homes currently under construction and estimated total completed value?

$5,000 $10,000

BICBLDRSK 03-16 Page 1 of 2

Remodel/Rehabilitation

NEW CONSTRUCTION PROJECT

Builders Risk- Monthly Reporting - Application

PROTECTION

FIRE PROTECTION

BICBLDRSK 03-16 Page 2 of 2

Is the job site fenced?

Is the job site lighted?

Are the streets lighted?

Building in an established subdivision?

Is the subdivision gated?

Is the subdivision gate guarded?

Does a security service patrol the subdivisions where the job sites are located?

Does the builder request law enforcement patrol from local authorities for the job

sites?

Is an alarm service used?

Are material appliances and HVAC equipment always installed immediately upon

delivery? If no, how are they secured?

Any other job site security measures used by the builder?

Yes No

Yes

Yes Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

NoNo

No

No

No

No

No

No

Is the responding Fire Department: Distance to the responding Fire Department: Are there working fire hydrants?Is yes, distance to fire hydrant?

If not, describe private protection available:Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree.

DateSignature of Applicant

Paid5 miles or less Yes1000 feet or less

VolunteerMore than 5 miles NoOver 1000 feet