BUILDERS RISK
				NEW / GROUND-UP
				CONSTRUCTION
Insureds Name:
DBA Name:
Street Address:
State:		Select Maryland Pennsylvania Delaware New Jersey Virginia Washington DC
County:
Insured is:		Select Owner Contractor
# of Years in Business:
Contractor Information
	Name:
	Mailing address:
Any Claims past 3 Years:				Select Yes No
If claims, please provide details:
Project Information
Location Address:
Project Type:		Select Single Family Two Family Commercial
Protection Class:			Select 1 2 3 4 5 6 7 8 9 10
City Limits:		Select Inside Outside
Distance to nearest
working hydrant:
Distance to nearest
responding fire department:
Distance from coastal waters:					Feet		Miles
Total Square foot area:
Number of stories:
Number of buildings:
Approximate distance between buildings:
Intended occupancy:
Construction type:			Select Frame Masonry Joist Noncombustible Masonry Noncombustible Fire Resistive
(see descriptions below)
Frame - Walls are constructed of wood or other combustible materials,
including when combined with other materials such as brick veneer, stone
veneer, wood ironclad, or stucco on wood.
Masonry Joist - Walls are constructed of masonry materials such as clay,
adobe, brick, gypsum block, cinder block, hollow concrete block,stone
tile, glass block, or other similar material and where the floors and/or
roof are combustible.
Noncombustible - Walls, floors, roof are constructed of and supported
by metal, asbestos, gypsum, or other noncombustible material.
Masonry Noncombustible - Walls are constructed of masonry materials of
the type described in masonry joist above, but with a floor and roof
constructed of metal or other noncombustible material.
Fire Resistive - Walls, floors and roof are constructed of fire resistive
materials having a resistance rating of not less than two (2) hours.
Nearest exposed structure:
	Occupancy:
	Distance to:
	Construction:		Select Frame Masonry Joist Noncombustible Masonry Noncombustible Fire Resistive
Are buildings transferred to permanent
coverage when completed:					Select Yes No
If yes, please advise the maximum number of buildings
under construction at any one time and the
corresponding values:
Does site have:
	Fencing:		Select Yes No
	Lighting:		Select Yes No
	Watchmen Service:			Select Yes No
	Watchmen hours on site:
	Debris removal from site at regular intervals:						Select Yes No
		Frequency:
	Public water supply in service:				Select Yes No
	Brush area:		Select Yes No
		If yes, clearance from site:
Name & Address of Loss Payees:
Estimated Start date of project:
Estimated completion date:
Estimated term of project:					Months
Currently under construction:				Select Yes No
	If yes, original start date:
	If yes, % completed:
	If yes, values completed:
Total completed value of project:
Temporary storage:
Loss Limit (if applicable):
Transit Limit:
Optional Coverages
Windstorm:		Select No Coverage Wanted Coverage Wanted
	Is Project eligible for coverage in a wind pool:						Select No Coverage Wanted Coverage Wanted
	If yes - maximum limit available in the wind pool:
Earthquake:		Select No Coverage Wanted Coverage Wanted
	ISO earthquake zone:			Select N/A 1 2 3 4 5
Flood:		Select No Coverage Wanted Coverage Wanted
	FEMA flood zone:			Select N/A A B C X V
	If zone A or V, 100 year base flood elevation:
	If zone A or V, eleavation of first finished floor:
Soft Costs:
Loss of rents:
Loss of earnings:
Deductible:		Select 500 1,000 2,500 5,000
Prior Carrier:
Prior Premium:
Agency Name:
Agency Address:
Agency Phone:
Agency Fax:
Agency Contact:
Contact E-Mail Address:
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								(Version 1)