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Builders Coverage Application
Application
DATE:
APPLICANT NAME:
ADDRESS:
CITY
STATE
ZIP:
EMAIL
PHONE NUMBER: FAX
NUMBER:
INSPECTION (CONTACT/PHONE):
ACCOUNTING RECORDS (CONTACT/PHONE):
OWNER
DEVELOPER
CONTRACTOR
OTHER
(DESCRIBE):
NAME OF CONTRACTOR:
OPTION I
OPEN REPORTING (If
applicable) Please complete Supplemental Info Section at end with any
upcoming years projects.
JOB DESCRIPTION
PLEASE DESCRIBE TYPE OF WORK PERFORMED.
CONSTRUCTION TYPE: Please estimate percentage of each type of
construction done per year.)
1. FRAME
%
MASONRY
%
NON-COMBUSTIBLE
%
FIRE RESISTIVE
%
2. NEW CONSTRUCTION
%
RENOVATION (if any)
%
ANNUAL NUMBER OF PROJECTS:
VALUE OF PROJECTS: AVG: $
MAX: $MIN:
$
LENGTH OF PROJECTS: AVG:
MAX:
MIN:
OPTION II
SPECIFIC JOB (If applicable)
LOCATION(S) OF JOB SITE:
LENGTH OF PROJECT:
CONSTRUCTION TYPE
FRAME:
%
MASONRY:
%
NON-COMBUSTIBLE:
%
FIRE RESISTIVE:
%
TRANSIT LIMIT: $
TEMPORARY
STORAGE LIMIT: $
FLOOD
PER
OCCURRENCE LIMIT & ANNUAL AGGREGATE $
SUBLIMIT
$
DEDUCTIBLE
$
:COVERAGE EXTENSIONS (Some Forms Automatically Include Some
Extensions)
| Fencing, Cribbing, Scaffolds & Construction Forms
$5,000 (Included) |
Increased Limit $ |
| Trees, Shrubs, Lawns, And Signs (Included) |
Increased Limit $ |
| Valuable Papers $10,000 (Included) |
Increased Limit $ |
| Fire Protective Systems Max $75,000 (Included) |
Increased Limit $ |
| Contract Penalty $10,000 (Included)
|
Increased Limit $ |
| Debris Removal $10,000 (Included) |
Increased Limit $ |
| Pollution Cleanup Up To $10,000 |
Increased Limit $ |
| Building Ordinance - 10% Of The Basic Limits Or
$100,000 |
Increased Limit $ |
ADDITIONAL COVERAGES
(Scheduled Limit to be Shown in the Declarations)
ADDITIONAL INTERESTS
GENERAL COMMENTS (Please attach Breakdowns of values; plot plans, etc.)
LOSS HISTORY
Enter all losses for the prior five (5) years.
The description of coverages in these pages is presented as
information only and all coverages will be subject to the terms and
conditions of the policy.
Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance containing
any false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime.
Please click on the "Submit Quote" button
to send your quote request.
One of our representatives will respond to your submission as soon as
possible. |