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Builders Risk- Monthly Reporting - Application
Application Date: Agency: Producer: Effective Date:
APPLICANT INFORMATION
Business Type IndividualApplicant Name: Mailing Address: Partnership
Corporation
LLCLocation 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 DEDUCTIBLESAOP 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
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.
DateSignature of Applicant
Paid5 miles or less Yes1000 feet or less
VolunteerMore than 5 miles NoOver 1000 feet