| BUILDERS RISK APPLICATION |
| Proposed Effective Date: |
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| Name Insured: |
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| Mailing Address: |
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| City: |
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| State: |
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| Zip Code: |
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| 1. |
# of years in business: |
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| 2. |
Has contractor completed this type
of project before? |
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| 3. |
Employee training? |
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| 4. |
Loss prevention program? |
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| 5. |
Any builders risk/installation losses
for past 3 years? |
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If yes, describe loss(es): |
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| 6. |
Average # of jobs in last 12 months: |
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| 7. |
Estimated annual receipts: |
$ |
 |
| Construction Site Information |
| 1. |
Location: |
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City: |
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County: |
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State: |
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Zip Code: |
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| 2. |
Construction Type: |
Frame
Joisted Masonry
Non-Combustable
Masonry Non-Combustible
Fire Resistive |
| 3. |
Roof Type: |
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Floors: |
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Support Framing/Studs: |
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Exterior Walls: |
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| 4. |
Square Footage: |
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| 5. |
# of stories: |
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| 6. |
Is this a remodel/renovation/installation
project? |
Yes
No |
| 7. |
Intended use/occupancy of structure: |
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| 8. |
Protection class: |
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| 9. |
Distance to fire hydrant: |
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| 10. |
Distance to fire dept.: |
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| 11. |
# of Firewalls: |
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Firewall rating # of hours: |
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When will firewalls be put in use: |
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When will doors be installed: |
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| 12. |
Anticipated start date: |
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| 13. |
Anticipated completion date: |
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| 14. |
Site security: |
No security
Watchman/guard 24 hrs
Watchman/guard night only
Lighted
Fenced
Other
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If other, please specify: |
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| Coverage/Limits Information |
| 1. |
Deductible: |
$1,000
$2,500
$5,000
$10,000
$25,000
Other
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If other, please specify: |
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| 2. |
Mortgagee/
Loss Payee/
Additional Interest
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| 3. |
Owners Name/Mailing Address: |
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| 4. |
Estimated completed value: |
$ |
| 5. |
Transit coverage: |
None
$25,000
Other
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| 6. |
Property temporarily at other locations: |
None
$25,000
Other
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| 7. |
Testing Coverage: |
No
Yes
Limit
$
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If yes, provide details: |
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| Completed By: |
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| Phone Number: |
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| Email Address: |
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