Application
Agency name
Agency producer #
Insured name *
Insured address line 1 *
Insured address line 2
Insured city * State: Zip:
Type of construction * Residential (1-4 Single Family Dwellings)
Commercial
Construction material * Frame
Protection class *
Policy period *
to
One Year from Effective Date
(12:01 a.m. Standard Time at your mailing address above.)
Has the project started? * Yes No
If yes, date started
Percent complete % If more than 30%, underwriter approval required
Property state
Additional insured #1 *
Additional insured address #1 *
Additional insured #2
Additional insured address #2
Notes
LOCATION INFORMATION:
Property address line 1 *
Property address line 2
Property city * State: Zip:
Property county *
Value of all covered property at *
all locations
Type of policy * New Construction, Remodelers
Is existing structure coverage desired? *
Do you have any additional insureds? *
Is the builder's name different than the named *
insured?
If yes, please enter Builder's Name:
Deductible *
If other, please enter amount: Numeric
Is the structure modular? Yes No * If yes, underwriting approval required, and modular
questions will be asked
Is the location apartments, condominiums or multi-unit * If yes, apartment occupancy questions will be asked.
structure(s)? Yes No
Estimated length of project *
Form of Business *
Any one structure * $ (numeric only)
Property temporarily at any other premises $ 10,000
Property in transit $ 25,000
All covered property at all locations * $
Any coverage for development / subdivision fences, walls *
or signs If Yes, please enter coverage amount:
$0(numeric only)
Rate Rate is per $100
Original rate
Does builder/remodeler have at least 2 years experience? *
If No, underwriter approval required
Business description * Homebuilder, Commercial GC, Remodeler*
*If remodeler, any foundation, structural change
load bearing walls? Yes No
If yes, underwriter approval required
Is the contractor insuring more than one building being constructed * Yes No
within 100 feet from each other at this project site? *If yes, please provide total estimated complete
structures under construction within 100 feet an
including this one:
$0 If > $5M refer to underwriting
Number of structures built/remodeled during the past 12 months? * 1-2 3-50 Other
If other, indicate number
Number of structures projected for the next 12 months? * 1-2 3-50 Other
If other, indicate number
Loss experience for last 3 years? Indicate cause of loss for any claim * Underwriter approval required if any loss
over $5,000
Do you want a certificate of insurance now? *
Do you wish to attach special instructions for the underwriter? *
Is there a sales contract on this structure? *
Type of security to be provided *
**Complete if Modular Construction
Who provides transit coverage? *
How are homes transported to the job site? *
Estimated time to complete each structure *
Does the manufacturer put the four sides together and then the builder *
finish it off?
Does the manufacturer have a web site address? *
If yes, enter the web address:
**Complete if in Coastal County
Excluding wind coverage? Yes No *
Is this structure located within 1,000 feet of tidal water or located *
on a barrier island?
When will construction be coming out of the ground? *
Percent complete by November 1? *
Where and how are materials stored? *
What preventative measures are taken to mitigate losses from *
windstorm?
Is building being constructed on pilings? *
If yes, what is the piling depth?:
Is location shielded by hills, buildings or any type of wind block? *
If yes, describe:
**Complete if Multiple Buildings or Multiple Units in Building
Number of buildings *
Number of units per building *
Value per building *
Distance between buildings *
Total project completed value *
Start and completion date of each building *
Enter both dates in field - XX/XX/XXXX-XX/XX/XXXX
Will the structure be occupied during construction? * Yes No
If yes, describe (and underwriting approval will be required
**Complete if Remodeler
Age of dwelling * If more than 75 years, underwriter approval required.
Is the existing structure considered historical? * If yes, underwriter approval required.
Is the remodeling work on the existing structure to begin * If no, underwriter approval required.
within 60 days of the effective date?
When was the heating system last updated? *
When was the electrical system last updated? *
Purchase price of shell * $ May not exceed actual cash value. Numeric
Amount of renovation/improvements * $ Numeric Only. If less than of purchase price
required.
Is profit included in renovation/improvements amount? *
**Complete if PC 9-10
Number of miles to the fire station *
Is fire department manned 24 hours a day? *
Is this fire department volunteer or paid? *
Response time necessary to notify station and get trucks to the site *
Number of pumper trucks available * Numeric
Source of water for pumper trucks *
Number of tanker trucks available * Numeric
Are there currently any fire hydrants on site? *
If no, what alternate source of water is
at the site for use in the even of a fire?
Will fire hydrants be installed and working prior to the start of the *
construction as part of the contract?
Distance to nearest fire hydrant *
Will the fire department have clear, unobstructed access to the *
construction site during the entire duration of the construction project?
Is a telephone (permanent line, cellular, etc.) available at the site at all *
times?
Is there a 911 service available in the area? *
Mortgagee name *
Mortgagee address line 1 *
Mortgagee address line 2
City * State Zip
Special instructions to the underwriter *