| State: |
|
County: |
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| Type of project: |
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| Type of Property:
Residential
Commercial |
| Policy Effective Date:
|
| Property Address 1: |
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Property Address 2: |
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| City: |
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Zip code: |
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| 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: |
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Protection Class: |
|
| Will existing structure be occupied during construction: |
Yes
No |
| If yes, by whom? |
|
If Other, enter description: |
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| 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: |
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State: |
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| Zip code: |
|
|
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| Phone: |
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Contact Person:
|
| Fax: |
|
|
|
Comments:
|
| 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 |
