BUILDERS RISK FORM Agency Name*Agency Contact Name* First Last Agency Contact Email* Agency Phone #*Agency Fax #Applicant Name* First Last Is Applicant Owner or Contractor:*OwnerContractorMailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Risk location* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Construction type:*Number of stories:*Square Footage of dwelling/building:*In City Limits:*YesNoHow many feet to fire hydrant:*How many miles to fire department:*Name of responding Fire Department:*Miles to fire department:*What is the nearest water source & how far away (IE pond, hydrant, etc):*New construction or Renovation:*New ConstructionRenovationWhat is ACV of existing structure:Budget for the renovation:Original Year Built:Describe in detail what the renovations will be:Is this Residential or Commercial:*ResidentialCommercialWhat is the intended occupancy:Expected date project to begin:*Expected date project to end:*Completed value: $*Deductible: $*Licensed Contractor Name* First Last Licensed Contractor Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contractor’s Phone #*Contractor Years of experience*Name of mortgagee (if applicable)Address of mortgagee (if applicable) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code