Construction / Renovation Insurance Expanded Form

What is your first name? **
What is your first name? *
What is your last name? **
What is your last name? *
What is your email address? **
What is your email address? *
What is your phone number? **
What is your phone number? *
Please provide your occupation and employer?
Please provide your occupation and employer?
What is your date of birth? **
What is your date of birth? *
MM slash DD slash YYYY
Form Options

Please select the insurance company/companies for which you would like to generate an application. **
Please select the insurance company/companies for which you would like to generate an application. *
- Berkley One
- Chubb
- Cincinnati Insurance
- PURE Insurance
- Other

What is the address/lot number where the construction/renovation will take place? **
What is the address/lot number where the construction/renovation will take place? *

Street Address Address Line 2 City State ZIP Code
Is this your mailing address as well? **
Is this your mailing address as well? *
- Yes
- No
What is your mailing address? **
What is your mailing address? *

Street Address Address Line 2 City State ZIP Code
Do you have insurance for this property currently?
Do you have insurance for this property currently?
- Yes
- No
What is the name of the insurance company?
What is the name of the insurance company?
Are you planning to purchase this property?
Are you planning to purchase this property?
- Yes
- No. The property is already owned.
What is the closing date? 1
What is the closing date?
MM slash DD slash YYYY
What is the purchase price?
What is the purchase price?
General Project Information
Is this a new construction or a renovation project? **
Is this a new construction or a renovation project? *
- New Construction
- Renovation
Please select the type(s) of structure(s) you will be constructing.
Please select the type(s) of structure(s) you will be constructing. (Select all that apply)
- New House
- Guest House
- Detached Garage
- Barn
- Pool
- Pool House
- Pool Enclosure
- Other
What year was the home built?
What year was the home built?
What is the total estimated cost of construction for your new house?
What is the total estimated cost of construction for your new house?
What will the square footage of your new house be?
What will the square footage of your new house be?
What type of construction will this new house be?
What type of construction will this new house be?
- Frame
- Masonry
- Masonry veneer
- Non-Combustible
- Fire Resistive (No wood in structure)
- Brick
- Stucco over frame
How many stories will your new house have?
How many stories will your new house have?
Are you planning to purchase this property? 2
Are you planning to purchase this property?
- Yes
- No. The property is already owned.
What is the closing date? 2
What is the closing date?
MM slash DD slash YYYY
Please describe the other structure(s) you will be constructing.
Please describe the other structure(s) you will be constructing.
What is the total estimated cost of construction for the guest house?
What is the total estimated cost of construction for the guest house?
What will the square footage of your guest house be?
What will the square footage of your guest house be?
How many stories will your guest house have?
How many stories will your guest house have?
What type of construction will this guest house be?
What type of construction will this guest house be?
- Frame
- Masonry
- Masonry veneer
- Non-Combustible
- Fire Resistive (No wood in structure)
- Brick
- Stucco over frame
What is the total estimated cost of construction for the detached garage?
What is the total estimated cost of construction for the detached garage?
What will the square footage of the detached garage be?
What will the square footage of the detached garage be?
How many stories will the detached garage have?
How many stories will the detached garage have?
What type of construction will this detached garage be?
What type of construction will this detached garage be?
- Frame
- Masonry
- Masonry veneer
- Non-Combustible
- Fire Resistive (No wood in structure)
- Brick
- Stucco over frame
What is the total estimated cost of construction for the barn?
What is the total estimated cost of construction for the barn?
What will the square footage of the barn be?
What will the square footage of the barn be?
How many stories will the barn have?
How many stories will the barn have?
What type of construction will this barn be?
What type of construction will this barn be?
- Frame
- Masonry
- Masonry veneer
- Non-Combustible
- Fire Resistive (No wood in structure)
- Brick
- Stucco over frame
What is the total estimated cost of construction for the pool?
What is the total estimated cost of construction for the pool?
What is the total estimated cost of construction for the pool house?
What is the total estimated cost of construction for the pool house?
What is the total estimated cost of construction for the pool enclosure?
What is the total estimated cost of construction for the pool enclosure?
What is the total estimated cost of construction for the other structure(s)?
What is the total estimated cost of construction for the other structure(s)?
What is the estimated completed value of the other structures?
What is the estimated completed value of the other structures?
What is the expected total cost of this new construction project? (Labor and materials, contractor profit and overhead, architect fees, interior designer fees, engineering or other speciality contractor fees, cost of cut, fill or backfill for site work, landscaping to be installed including plants and trees.) **
What is the expected total cost of this new construction project? (Labor and materials, contractor profit and overhead, architect fees, interior designer fees, engineering or other speciality contractor fees, cost of cut, fill or backfill for site work, landscaping to be installed including plants and trees.) *
Please select the areas that will be included in your renovation.
Please select the areas that will be included in your renovation. (Select all that apply)
- Kitchen
- Bathroom(s)
- Moving load bearing walls
- Refinishing hardwood floors
- Deck
- Patio
- Painting
- Adding an addition
- Finishing the basement
- Roof
- Other
Please describe the other areas that will be part of this renovation.
Please describe the other areas that will be part of this renovation.
What is the estimated home square footage before the project begins?
What is the estimated home square footage before the project begins?
How much square footage is being added with this addition?
How much square footage is being added with this addition?
What is the current replacement cost of the existing home?
What is the current replacement cost of the existing home?
What is the total estimated cost for this renovation project?
What is the total estimated cost for this renovation project?
What is the estimated completed value of the dwelling? (The sum of the replacement cost and the project cost will be the estimated completed value.)
What is the estimated completed value of the dwelling? (The sum of the replacement cost and the project cost will be the estimated completed value.)
Will you continue to occupy the residence during the renovation?
Will you continue to occupy the residence during the renovation?
- Yes
- No
- Not sure
What is the address where you will live during the renovation?
What is the address where you will live during the renovation?

Street Address Address Line 2 City State ZIP Code
How long do you plan to be out of your home?
How long do you plan to be out of your home?
Will any of your personal property be stored at this residence during the renovation?
Will any of your personal property be stored at this residence during the renovation?
- Yes
- No
What is the approximate value of the personal property that will be stored at this residence during the renovation?
What is the approximate value of the personal property that will be stored at this residence during the renovation?
Will any structure(s) be demolished as part of this project?
Will any structure(s) be demolished as part of this project?
- Yes
- No
- Not sure
Please provide a brief description of the demolition work and the structure(s) being demolished.
Please provide a brief description of the demolition work and the structure(s) being demolished.
Please provide a general description and/or additional information about the work to be done below. **
Please provide a general description and/or additional information about the work to be done below. *
Construction/Renovation Optional Coverages
Do you want to add coverage for soft costs (I.e. architect's fees, designer's fees, taxes, insurance, etc.)
Do you want to add coverage for soft costs (I.e. architect's fees, designer's fees, taxes, insurance, etc.)
- Yes
- No
- Not sure
Please select the coverage limit you would like for soft costs.
Please select the coverage limit you would like for soft costs.
Do you want coverage for construction materials in transit/away from the premises?
Do you want coverage for construction materials in transit/away from the premises?
- Yes
- No
- Not sure
Please select the coverage limit you would like for materials in transit/away from the premises.
Please select the coverage limit you would like for materials in transit/away from the premises.
Project Schedule
Has construction already started? **
Has construction already started? *
- Yes
- No
What percentage of the work is complete? **
What percentage of the work is complete? *
Please explain why coverage is being requested at this time. **
Please explain why coverage is being requested at this time. *
Has there been any coverage up to this point? **
Has there been any coverage up to this point? *
- Yes
- No
What insurance company is currently covering this project? **
What insurance company is currently covering this project? *
How many days a week is the builder working at this site? **
How many days a week is the builder working at this site? *
What date will this project begin?
What date will this project begin?
MM slash DD slash YYYY
What date will the new construction be fully enclosed and the electrical roughed in?
What date will the new construction be fully enclosed and the electrical roughed in?
MM slash DD slash YYYY
What date will this project be completed?
What date will this project be completed?
MM slash DD slash YYYY
Do you intend to occupy the home upon project completion?
Do you intend to occupy the home upon project completion?
- Yes, I intend to occupy this residence.
- No
What is the intended occupancy of this home upon project completion?
What is the intended occupancy of this home upon project completion?
Interested Parties
Will there be a mortgage for this project?
Will there be a mortgage for this project?
- Yes
- No
- Not sure
What is the name of the bank providing the mortgage?
What is the name of the bank providing the mortgage?
Who is your contact at the bank?
Who is your contact at the bank?
What is the phone number for your contact at the bank?
What is the phone number for your contact at the bank?
What is the email address for your contact at the bank?
What is the email address for your contact at the bank?
Will the insurance premium be escrowed?
Will the insurance premium be escrowed?
- Yes
- No
- Not sure
Is there a mortgage?
Is there a mortgage?
- Yes
- No
Please enter the bank name, if convenient.
Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient.
Please enter the bank address, if convenient.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please enter the loan number, if convenient.
Please enter the loan number, if convenient.
Is the insurance premium being escrowed?
Is the insurance premium being escrowed?
- Yes
- No
- Not sure
Trust or LLC
Is there a Trust, LLC or Limited Partnership involved in the ownership of this property?
- Yes
- No
Legal Entity Information

Trust or LLC Name
Please enter the name of the Trust, LLC or Limited Partnership:
What is the type of legal entity?
What is the type of legal entity?
Please enter the type of legal entity:
Please enter the type of legal entity:
Is there a tax ID or FEIN? **
Is there a tax ID or FEIN? *
- Yes
- No
Please enter the tax ID or FEIN.*
Please enter the tax ID or FEIN.
Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...)
Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...)
Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you. **
Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you. *
Principal/Beneficial Owner Name/Trustee(s) Relationship to you
Who uses or possesses the entity owned asset?
Who uses or possesses the entity owned asset?
Who is responsible for the maintenance of the entity owned asset?
Who is responsible for the maintenance of the entity owned asset?
What is the purpose or intent of the entity?
What is the purpose or intent of the entity?
Does the entity generate income or conduct business with regards to the appreciation of owned property...
Does the entity generate income or conduct business with regards to the appreciation of owned property, private residential rental income, management of wealth for the benefit of the principal owners or incidental business?
- Yes
- No
Please provide details about the income generation and business conducted by this entity.
Please provide details about the income generation and business conducted by this entity.
Does the entity generate income in any other ways?
Does the entity generate income in any other ways?
- Yes
- No
Please provide a description of the other ways this entity generates income.
Please provide a description of the other ways this entity generates income.
Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
- Yes
- No
Please list the other assets this entity owns:
Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Does the entity have any employees?
Does the entity have any employees?
- Yes
- No
Please list the name and occupation for each of the employees:
Please list the name and occupation for each of the employees:
Name Occupation
Please describe how the employees are paid.
Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Does the entity maintain any other insurance policies?
Does the entity maintain any other insurance policies?
- Yes
- No
Please provide the insurance company name(s), coverage type and coverage limits for the other policies.
Please provide the insurance company name(s), coverage type and coverage limits for the other policies.

Have you selected a general contractor for this project?
Have you selected a general contractor for this project?
- Yes
- Not yet
- I will be the general contractor
Will you hire subcontractors for any of the work?
Will you hire subcontractors for any of the work?
- Yes
- No
What date will you select your general contractor?
What date will you select your general contractor?
MM slash DD slash YYYY
General Contractor Information

What is the name of the general contractor's business?
What is the name of the general contractor's business?
Please enter the general contractor's website address.
Please enter the general contractor's website address.
Please enter the site foreman/project manager's name.
Please enter the site foreman/project manager's name.
Please enter the site foreman/project manager's phone number.
Please enter the site foreman/project manager's phone number.
Please enter the site foreman/project manager's email address.
Please enter the site foreman/project manager's email address.
What is the contractor's tax-ID number?
What is the contractor's tax-ID number?
How many years has the general contractor's company been in business?
How many years has the general contractor's company been in business?
Please list all other company names and FEINs used in the last five years.
Please list all other company names and FEINs used in the last five years.
Please enter the general contractor's license number.
Please enter the general contractor's license number.
Please list the states the GC is licensed in as a general contractor.
Please list the states the GC is licensed in as a general contractor.
How many projects does the GC typically start and complete in one year?
How many projects does the GC typically start and complete in one year?
How many projects does the GC have underway currently?
How many projects does the GC have underway currently?
Please enter the general contractor's business address.
Please enter the general contractor's business address.

Street Address Address Line 2 City State ZIP Code
Do you have a certificate of insurance from the general contractor listing you as an additional insured and certificate holder?
Do you have a certificate of insurance from the general contractor listing you as an additional insured and certificate holder?
- Yes
- No
Please upload the certificate of insurance for the general contractor so we can review it for coverage adequacy.
Please upload the certificate of insurance for the general contractor so we can review it for coverage adequacy.
Max. file size: 128 MB.
Does the general contractor have a builders risk policy in effect for this project?
Does the general contractor have a builders risk policy in effect for this project?
- Yes
- No
- Not sure
Will the general contractor be hiring subcontractors?
Will the general contractor be hiring subcontractors?
- Yes
- No
- Not sure
Does the GC require all subcontractors to carry Commercial General Liability (CGL) and Workers Compensation Insurance?
Does the GC require all subcontractors to carry Commercial General Liability (CGL) and Workers Compensation Insurance?
- Yes
- No
Does the GC require all subcontractors to submit Certificates of Insurance as part of the subcontract bid process?
Does the GC require all subcontractors to submit Certificates of Insurance as part of the subcontract bid process?
- Yes
- No
Do you have a contract with the general contractor?
Do you have a contract with the general contractor?
- Yes
- No
- Not sure
Please upload a copy of the signed contract.
Please upload a copy of the signed contract.
Max. file size: 128 MB.
Does your contract include a waiver of subrogation?*
Does your contract include a waiver of subrogation?
- Yes
- No
- Not sure
Have you signed a waiver of subrogation with your contractor?*
Have you signed a waiver of subrogation with your contractor?
- Yes
- No
- Not sure
Please enter a description of the 5 most recent projects the general contractor has completed and their total square footage. (Skip this if the information is not available at this time)
Please enter a description of the 5 most recent projects the general contractor has completed and their total square footage. (Skip this if the information is not available at this time)
Project Description Square Foot Value of Work ($)
Have any of the projects the GC worked on in the past 5 years suffered a property loss or claim?
Have any of the projects the GC worked on in the past 5 years suffered a property loss or claim?
- Yes
- No
Has the GC been the subject of a lawsuit or suffered a Worker's Compensation loss in the past years?
Has the GC been the subject of a lawsuit or suffered a Worker's Compensation loss in the past years?
- Yes
- No
Please provide the approximate date and a description of the claim(s) or lawsuit(s) below. **
Please provide the approximate date and a description of the claim(s) or lawsuit(s) below. *
Date Description

Risk Management on Site
Has the general contractor provided a written construction plan that defines security and fire protection that will be maintained on this site during each construction phase of the project?
Has the general contractor provided a written construction plan that defines security and fire protection that will be maintained on this site during each construction phase of the project?
- Yes
- No
Please upload a copy of the construction plan that defines security and fire protection for each phase of this project, if available.
Please upload a copy of the construction plan that defines security and fire protection for each phase of this project, if available.
Max. file size: 128 MB.
Will an active central station burglar and fire alarm system be in place once the structure is enclosed? **
Will an active central station burglar and fire alarm system be in place once the structure is enclosed? *
- Yes
- No
Please select all risk management strategies that will be employed during the project.
Please select all risk management strategies that will be employed during the project.
- Fire extinguisher(s)
- No smoking sign(s)
- Fire proof storage cabinet for flammable liquids
- No trespassing sign(s)
- Driveway chain
- Temporary/permanent central station fire alarm
- Temporary/permanent central station burglar alarm
- Full perimeter security fencing
- Motion activated security lighting
- Automatic water shutoff valve
- Guard gated community
- Security guard or watchmen
- Monitored exterior video surveillance system
- Contractor signage
- Disconnect all extension cords and remove debris daily
- Residential fire sprinkler water flow alarms
- Hot works program
- Vibration sensors
- Other
Provide a brief description of the other risk management strategies that will be employed.
Provide a brief description of the other risk management strategies that will be employed.
Please upload a picture of the fire extinguisher(s) on site, if convenient.
Please upload a picture of the fire extinguisher(s) on site, if convenient.
Drop files here or

Max. file size: 128 MB.
Please upload a picture of the "No Smoking" sign(s) on site, if convenient.
Please upload a picture of the "No Smoking" sign(s) on site, if convenient.
Drop files here or

Max. file size: 128 MB.
Please upload a picture of the driveway chain, if convenient.
Please upload a picture of the driveway chain, if convenient.
Drop files here or

Max. file size: 128 MB.
Please upload a copy of an alarm certificate from your alarm company, if convenient.
Please upload a copy of an alarm certificate from your alarm company, if convenient.
Drop files here or

Max. file size: 128 MB.
Insured's Signature
Please print your full name.
Please print your full name.
Please sign your name in the space below.
Please sign your name in the space below.
Please enter your position, if applicable. (Ie. Owner, etc.)
Please enter your position, if applicable. (Ie. Owner, etc.)
Please enter today's date.
Please enter today's date.
MM slash DD slash YYYY
Documents and Comments
Please use this field to upload any relevant insurance documents. (Ie. Project contract, Contractor's certificate of insurance, etc...)
Please use this field to upload any relevant insurance documents. (Ie. Project contract, Contractor's certificate of insurance, etc...)
Drop files here or

Max. file size: 128 MB, Max. files: 5.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
How did you hear about us?
How did you hear about us?
Please share who referred you to us.
Please share who referred you to us.
Can you share what you typed into Google?
Can you share what you typed into Google?
Please let us know how you heard about us.
Please let us know how you heard about us.
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 *

Ali (TEST) Jafarian

Construction / Renovation Insurance Expanded Form's Bio

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Construction / Renovation Insurance Expanded Form

Form Options

General Project Information

Construction/Renovation Optional Coverages

Project Schedule

Interested Parties

Legal Entity Information

General Contractor Information

Risk Management on Site

Insured's Signature

Documents and Comments

Ali (TEST) Jafarian

RiskRevu^TM Newsletter

Contact

Principal/Beneficial Owner Name/Trustee(s)	Relationship to you

Name	Occupation

Project Description	Square Foot	Value of Work ($)

Date	Description

Construction / Renovation Insurance Expanded Form

Form Options

General Project Information

Construction/Renovation Optional Coverages

Project Schedule

Interested Parties

Legal Entity Information

General Contractor Information

Risk Management on Site

Insured's Signature

Documents and Comments

Ali (TEST) Jafarian

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