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Builders Risk Extension Questionnaire
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Contact 1 - First Name
What is your first name?
Contact 1 - Last Name
What is your last name?
Contact 1 - Email
What is your email address?
Builders Risk Type
Is this form being completed for a residential or commercial construction project?
Residential
Commercial
Named Insured?
Is the person completing this form the named insured on the Builders Risk policy?
Yes
No
Named Insured's Name
Please enter the named insured for this residential Builders Risk policy.
Commercial Named Insured Name
Please enter the named insured for this commercial Builders Risk policy.
Today's Date
Please enter today's date.
MM slash DD slash YYYY
Builders Risk Policy Number
Please enter the Builders Risk policy number.
The insured understands and acknowledges that the responses provided herein shall be reviewed by the Underwriter to determine whether the subject policy shall be extended and, if so, for what premium and with what changes to the terms and conditions of said policy. The insured agrees that the Underwriter reserves the right to cancel the policy or alter the terms, conditions, and premiums charged if any of the responses provided herein are inaccurate.
Construction Extension Questions
Reason(s) for Delay
Please provide a description of the reason(s) this construction project has been delayed.
Continuous Construction?
Has construction been continuous?
Yes
No
Continuous Construction Elaboration
Please elaborate on your answer that construction has not been continuous.
Any losses?
Has there been a loss of any kind?
Yes
No
Loss Elaboration Details
Please provide an overview and details about the loss or losses in the space below.
Preventative Measures Implemented?
Were any preventative measures put in place after the loss?
Yes
No
Not sure
Preventative Measures Details
Please provide details about the preventative measures that were put in place after the loss in the space below.
GC Confirmed No Losses
Has it been confirmed by the General Contractor that there are no known losses (or occurrences that could lead to a loss or claim) that have not already been reported to the carrier?
Yes
No
Hot Works Completed?
Are Hot Works completed?
Yes
No
Description of Remaining Hot Works
Please provide a description of the remaining Hot Works in the space below.
Percentage of Project Completed
*
What percentage of the project is completed? (e.g. 75%) *
Description of Remaining Work
*
Please provide values and a narrative describing the remaining work. *
What is the anticipated completion date? *
*
What is the anticipated completion date? *
Site Security Compliance
Is the site security for this project in compliance with the Protective Safeguards endorsement?
Yes
No
Not applicable
Site Security Description
Please provide an overview of the site security that is in place in the space below.
Building Fully Enclosed?
Is the building fully enclosed with all windows/external doors installed and weather sealed?
Yes
No
Projected Fully Enclosed Date
What is the date when the building is scheduled to be fully enclosed?
MM slash DD slash YYYY
Water On?
Has the water been turned on?
Yes
No
Sprinkler System Charged?
Is the sprinkler system charged and operational?
Yes
No
Not applicable
Alarm System Active?
Is the central and fire alarm system operational and active?
Yes
No
Not applicable
Certificate of Occupancy Status
Please select the status of the certificate of occupancy for this project.
Temporary certificate of occupancy was issued
Temporary certificate of occupancy is scheduled to be issued
Final certificate of occupancy was issued
Final certificate of occupancy is scheduled to be issued
Not applicable
Temporary Certificate of Occupancy Date
Please enter the date the temporary certificate of occupancy was issued.
MM slash DD slash YYYY
Temporary Certificate of Occupancy Scheduled Issue Date
Please enter the date the temporary certificate of occupancy is scheduled to be issued.
MM slash DD slash YYYY
Final Certificate of Occupancy Issue Date
Please enter the date the final certificate of occupancy was issued.
MM slash DD slash YYYY
Final Certificate of Occupancy Scheduled Issue Date
Please enter the date the final certificate of occupancy is scheduled to be issued.
MM slash DD slash YYYY
Building Occupancy Status
Please select the occupancy status of this project.
The building is not occupied
The building is occupied
The building is scheduled to be occupied
Date of First Occupancy
What date was the building first occupied?
MM slash DD slash YYYY
Building Percentage Occupied
What percentage of the building is occupied?
Date of Scheduled Occupancy
What date is the building scheduled to be occupied?
MM slash DD slash YYYY
Miscellaneous Comments Section
Additional Remarks
Please enter any additional comments about this construction project in the space below.
Relevant Documents
Please use this field to upload any relevant documents. (ie. Certificate of occupancy, etc...)
Drop files here or
Select files
Max. file size: 128 MB.
Consent
*
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
I agree
Kurt Thoennessen, CAPI
(203) 405-2645
http://ajg.com/
kurt_thoennessen@ajg.com
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