Builders Risk- Monthly Reporting - Application Application Date: Agency: Producer: Effective Date: APPLICANT INFORMATION Business Type Individual Applicant Name: Mailing Address: Partnership Corporation LLC Location 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 DEDUCTIBLES AOP 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
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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.