EmailMe Form - Builder's Risk Quote Form

Full Name

First Last

Phone

### - ### - ####

Email

Insured mailing address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Property Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Project Type

New Construction

Remodeling including coverage for the existing structure

Remodeling excluding coverage for the existing structure

Expected Effective Date

MM / DD / YYYY

Entity

Description of named insured

Contractor

Owner

Owner / Contractor

Is the builder’s name different than the named insured?

Yes

No

If "Yes" above:
What is builder’s name, address, City State, Zip code, and phone number?

Does builder / remodeler / owner / GC have at least 2 years experience?

Yes

No

Number of structures built / remodeled during the past 12 months?

Number of structures projected for the next 12 months?

Has the builder / remodeler had any single loss over $10,000 in the last 3 years?

Yes

No

If “Yes”, include the date, description, and amount of each loss

Property type

Residential (1-4 Single Family Dwellings / Units)

Commercial

Property protection class?

Number of stories

Construction material

Total completed value of structure (Limit)

Intended occupancy

Will structure be occupied during construction?

Yes

No

Square footage (Including basement)

Has the project started?

Yes

No

If “Yes”, date started

MM / DD / YYYY

Percent completed

Estimated length of project in MONTHS

ADDITIONAL INTERESTS

Additional interest type

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Fax

### - ### - ####

Email

COMMENTS

Please tell us anything else that might help us underwrite this business. Thanks.

Comment(s):