CONTACT US

IS THE HOME MORE THAN 50% COMPLETE?

Yes

No

Does Not Qualify

INSURED LEGAL NAME:

DBA:

MAILING ADDRESS:

Insured Contact Information

Name

First

Last

PHONE:

EMAIL:

INSUREDS FORM OF BUSINESS? INSUREDS FORM OF BUSINESS?

DESCRIPTION OF NAMED INSURED?

Owner/Contractor

Owner

Contractor

POLICY EFFECTIVE DATE

ADDRESS:

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Total Completed Value Of This Structure (Not Including Land)

AMOUNT (COST)

IS THE BUILDERS NAME DIFFERENT THAN THE INSURED?

Yes

No

YOUR COMMENT

DOES BUILDER/REMODELER/OWNER/GC HAVE AT LEAST 2 YEARS EXPERIENCE?

Yes

No

NUMBER OF STRUCTURES/PROJECTS PROJECTED FOR THE NEXT 12 MONTHS?

HAS THE BUILDER/REMODELER AND/OR STRUCTURE ITSELF HAD ANY SINGLE LOSS OR DAMAGE OVER $10,000 IN THE LAST 3 YEARS (INCLUDE INSURED/UNINSURED LOSSES/DAMAGES)?

Yes

No

WILL THE CONTRACTOR OR OWNER BE INSURING MORE THAN ONE BUILDING/STRUCTURE ON THIS POLICY?

Yes

No

WHAT IS THE CONSTRUCTION COST OF EACH INDIVIDUAL BUILDING?

TYPE OF PROJECT:

New Construction

Remodel

YEAR BUILT OF EXISTING STRUCTURE:

SCOPE OF WORK:

Remodel - Remodeling of interior finishes; exterior painting; replacement of interior fixtures, cabinets, flooring, etc. No structural changes.

Remodel/Minor Structural - Remodel work as listed above and minor changes to exterior (doors, windows, skylights, etc.). Roof replacement, ground floor additions and all non-structural changes such as HVAC, plumbing and electrical.

Restructuring - Repair, replace, remove load bearing walls. Adding additional stories, adding stairways or elevators. Foundation work such as underpinning and/or dewatering

AMOUNT OF RENOVATIONS /IMPROVEMENTS:

EXISTING BUILDING(S) OR STRUCTURE(S) AMOUNT (IF NEEDED):

CONSTRUCTION MATERIAL:

Frame - exterior walls constructed of wood or other combustible materials such as brick veneer, stone veneer, wood and stucco on wood.

Joisted Masonry - exterior walls constructed of masonry materials such as brick, concrete, block, stone or similar materials and the floors and roof are of wood construction.

Non-Combustible - exterior walls, floors and roof constructed of metal, gypsum or other non-combustible materials.

Masonry Non-Combustible - exterior walls, floors and roof constructed of masonry or fire resistive materials with fire resistance rating of not less than 1 hour.

Fire Resistive - exterior walls, floors and roof constructed of masonry or fire resistive materials with a fire resistance rating of not less than 2 hours.

NUMBER OF STORIES:

INTENDED OCCUPANCY:

Commercial Property

Single Family Dwelling

Habitational (greater than 1 unit)

WILL STRUCTURE BE OCCUPIED AT ANY TIME DURING THE POLICY TERM?

Yes

No

ANY PREVIOUS DAMAGE AT THIS LOCATION AS A RESULT OF QUAKE, FLOOD, WIND, FIRE OR VANDALISM (INCLUDE INSURED AND UNINSURED DAMAGES)

Yes

No

IF YES, UNDERWRITER APPROVAL REQUIRED

IS THIS A MODEL HOME?

Yes

No

HAS PROJECT STARTED?

Yes

No

EXPECTED COMPLETION DATE:

IS THE STRUCTURE MODULAR?

Yes

No

ARE THERE ANY ADDITIONAL INSUREDS NEEDED?

Yes

No

INTEREST TYPE INTEREST TYPE

INTEREST NAME

INTEREST STREET

INTEREST CITY

INTEREST STATE

INTEREST ZIP

INTEREST PHONE

INTEREST LOAN NUMBER

Does Not Qualify

Insured Contact Information

ADDRESS:

Total Completed Value Of This Structure (Not Including Land)

QUICK LINKS

Useful Links

Contact Us