General Information
What is the insured's name? *
What is your first name? *
What is your last name? *
What is your email address? *
What is the your phone number? *
Are you the person who will schedule the inspection of this job site? *
What is the inspection contact person's full name?
What is the inspection contact person's phone number?
What is the inspection contact person's email address?
What is the applicant's primary mailing address? *
What date does the applicant need this insurance to commence?
MM slash DD slash YYYY
What date does the applicant need this insurance to be terminated?
MM slash DD slash YYYY
What type of legal entity does the applicant operate under?
Please describe the legal entity type the applicant operates under.
Is there a mortgage? *
Please enter the mortgage provider's name. *
Is the Applicant required to name loss payable interests as additional insureds?
Please provide the names of all certificate holders and additional insureds along with their interest.
What is the jobsite address where the new construction will take place?
What is the name of the architect?
What is the name of the engineer?
Please provide a description of the project. *
Limits of Insurance
Please enter the requested coverage amount for the job site? *
Please enter the requested coverage amount for items in storage at any location other than the project site? *
Please enter the requested coverage amount for items while in transit? *
Please enter the requested coverage amount for catastrophe risk? *
Select your preferred deductible.
General Contractor Information
What is the name of the general contractor's business?
Please enter the general contractor's business address.
Please enter the general contractor's website address.
How many years has the general contractor's company been in business?
Please describe the contractor's experience with projects like this one.
Have any of the projects the GC worked on in the past 5 years suffered a property loss or claim?
Please provide the approximate date and a description of the claim(s) below. *
Construction Details
Please select the building's construction type.
Please provide details about the construction types that will be used in this construction project. (Ie. first floor steel, upper floors frame) *
What will the completed value of the building be?
What date will construction begin?
MM slash DD slash YYYY
What is the estimated completion time of this project?
What will the total square footage of the building be?
How many floors will the building have?
How many floors will the building have above ground?
How many floors will the building have below ground?
What is the intended occupancy of this project when it is completed?
Is this construction lift slab or tilt up?
Will a modular construction method be used for this structure?
Modular Construction Details
What is the manufacturer's name?
What is the manufacturer's website address? (Include http://)
What is the design or plan number?
Please describe the foundation and how the home is moved onto the foundation.
What size are the floor joists? (i.e. 2x2, 2x4, 2x6, etc.)
Will the structure be constructed with I-beams and axles?
What building code is the structure built to?
How will the structure be transported to the job site?
Who provides insurance coverage for the structure in transit?
Does the manufacturer put the four sides together and then the builder finishes it off?
Optional Coverages
Please select the optional coverages you would like for this project? (Select all that apply)
Please enter the coverage amount you would like for damage caused by flooding.
Please enter the deductible you would like for flood claims.
Please enter the coverage amount you would like for damage caused by earthquake.
Please enter the deductible you would like for earthquake claims.
Delay In Completion Coverage Selection
Please select the delay in completion coverage options you would like to include for this project. (Select all that apply)
What coverage amount are you requesting for additional construction expenses? (Ie. Advertising, Design Fees, Financing, Lease Administration, Professional Fees & Permit Fees)
What coverage amount are you requesting for additional soft costs? (Ie. Interest Payments, Realty Taxes, Lease Expenses, Insurance Premiums)
What coverage amount are you requesting for rental income coverage?
What coverage amount are you requesting for income coverage?
What coverage amount are you requesting for sewer backup coverage?
What coverage amount are you requesting for expenses to reduce a loss coverage?
What coverage amount are you requesting for ordinance or law coverage?
What coverage amount are you requesting for interruption by civil authority coverage?
What coverage amount are you requesting for limited fungus coverage?
What coverage amount are you requesting for general administration expense coverage?
Risk Management on Site
What is the distance to the nearest operating fire hydrant?
What is the distance to the responding fire department?
What is the public fire protection class at the job site?
Please select all loss control strategies that will be employed during the project.
Provide a brief description of the other risk management strategies that will be employed.
Applicant's Signature
Please print your full name. *
Please sign your name in the space below. *
Please enter your position, if applicable. (Ie. Owner, etc.)
Please enter today's date. *
MM slash DD slash YYYY
Producer's Signature
Producer's full name.
Producer's signature.
Documents and Comments
Please use this field to upload any relevant insurance documents. (Ie. Project contract, etc...)
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Can you share what you typed into Google?
Please let us know how you heard about us.
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. *
