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Is the home more than 30% complete?
*
Yes
No
Is the protection class 9, 10 or ending in X?
*
Yes
No
Policy Effective Date:
*
Type of property
*
(1-4 Single Family Dwellings/Units)
Commercial
Property Address:
*
Property City:
*
Property State:
*
Property Zip:
*
Property County:
*
# of Separate Structures on this property?
1
2
3
4
5
6
7
8
9
10
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
What is the square footage? (including basement or garage)
Total completed value of this structure (not including land)
Total Completed Value of this structure (Not Including Land)
*
Insured Name
*
Mailing Address:
*
Insured Contact Name:
*
Insured Phone number
*
Insured Contact Email
*
Insureds form of business?
*
Corporation
Corporation
Individual
Joint Venture
LLC
Partnership
Other
Description of named insured?
*
Owner/Contractor
Owner
Contractor
Is the builders name different than the insured?
*
Yes
No
Name of Builder (If Yes)
Builder Address (If Yes)
Does builder/remodeler/owner/GC have at least 2 years experience?
*
Yes
No
Number of structures/projects projected for the next 12 months?
*
1-2
3-50
Other
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
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
*
Single Family Dwelling
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
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?
Interest Type
Additional Insured – Builder
Additional Insured – Other
Loss Payee
Mortgagee
Premium Finance Company
Interest Name
Interest Street
Interest City
Interest State
Interest Zip
Interest Phone
Interest Loan number
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Does not qualify!
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