Builders Risk Form

Agency Name*

Agency Contact Name*

First Last

Agency Contact Email*

Agency Phone #*

Agency Fax #

Is Applicant Owner or Contractor:*

Applicant Name*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Risk location*

Street Address Address Line 2 City State ZIP Code

Construction type*

Number of stories:*

Square Footage of dwelling/building:*

In City Limits:*

How 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:*

What 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:*

What 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

CAPTCHA