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 Builders Risk Quote 
Builders Risk Insurance Quote

Contact Information
Named Insured: Day Telephone:
Insured Address1: Eve Telephone:
Insured Address2: Fax:
City, State & Zip: Best Time To Reach You:
E-Mail Address:
Business Information
Insured Form of business:
If Other, describe:
Named Insured Description:
Is builder/contractor’s name different from named insured: Yes No
If yes, enter the builder as another named insured below:
Does the builder/contractor have at least 2 years experience building/remodeling: Yes No
Number of structures built/remodeled during the past 12 months: 1-2 3-50 Other
Number of structures projected for the next 12 months: 1-2 3-50 Other
Has the builder/remodeler had any single loss over $10,000 in the last 3 years (Include Insured/uninsured losses): Yes No
If Yes, include the date, description, and amount of each loss below:
Additional Interest
Interest type:
Address1: Address2:
City: State:
Zip code: Daytime Phone #:
Property Information
State: County:
Type of project:
Type of Property: Residential Commercial
Policy Effective Date:
Property Address 1: Property Address 2:
City: Zip code:
Are you insuring more than one building being constructed within 100 feet from each other at this project site: Yes No
If Yes, please provide total estimated completed values of all structures under construction within 100 feet and insured with us, including this one:
Construction Material: Protection Class:
Will existing structure be occupied during construction: Yes No
If yes, by whom? If Other, enter description:
Square Footage:
Has the project started: Yes No If Yes, Starting Date:
If Yes, % complete:
Is there a sales contract on the structure? Yes No
Estimated length of project: Months Years
Is structure modular: Yes No
Total completed value of any one structure: $
Value of covered property at all locations: $
Modular Information
Who provides transit coverage:
How are homes transported to the job site:
Does the manufacturer put the four sides together and then the builder finish it off: Yes No
Does the manufacturer have a web site address: Yes No
If yes, enter the web address:
If no, enter detailed specifications:
Design number or plan number:
Remodeling/Renovation Information
Amount of renovation/improvements: $
Existing building or structure(s) amount: $
Total complete value of all covered property: $
General Information
Requested Coverage Amount: $
Property State:
Type of Policy: New Construction Renovation Construction
Distance to fire hydrant (feet):
Distance to Responding Fire Department (miles):
Name of Fire Dept:
Flood Coverage: Yes No
Is the location apartments, condominiums, or multi-unit structures: Yes No
If remodel, any foundation, structural changes, or movement of load bearing walls: Yes No
Mortgagee Information
Mortgagee Name:
Street Address:
City: State:
Zip code:
Phone: Contact Person:
Renovation Information
Is existing structure coverage desired: Yes No
Age of Structure:
Is the existing structure considered historical: Yes No
Will the remodeling work on the existing structure begin within 60 days of the effective date: Yes No
Provide detail of improvements to be done:
Purchase price of existing structure (excluding land value): $
Amount of renovations/improvements: $
Is profit included in improvements amount: Yes No
Will existing structure be insured by another policy during construction? Yes No
Does the building have an operable sprinkler system? Yes No
Has the existing structure been moved or will it be moved as part of this project? Yes No
Date the existing structure was purchased:
Have any previous losses occurred at this location as a result of earthquake, flood, wind, fire, or vandalism? Yes No
If YES, Explain:
Provide a brief description of the structure to be renovated and the condition of the existing structure:
Commercial Information
Number of Stories: Intended occupancy:
Square Footage: Number of Structures:
Number of units per building: Value per building:
Distance between buildings (ft):
Total project completed value: $
Start and completion date of each building:
Will the structure be occupied during construction: Yes No
Any additional comments or information
that might be helpful in your quote

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