Builders Risk Application – Orr & Associates Insurance Services

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Builders Risk Application

"*" indicates required fields

First and Last Name*

Business Name (if applicable)

Phone*

Email*

Project Details

Is this a new construction or remodel project?*

New Construction

Remodel

Is this a residential or commercial project?*

Residential

Commercial

Other

Has the project already started?*

Yes

No

Project Start Date*

MM slash DD slash YYYY

Percentage Completed

From the beginning of the project until now, have there been any incidents or damage that may give rise to a claim?*

Yes

No

Applicant Information

What is your relation to the project?*

Contractor

Homeowner

Owner/Contractor

What is your relation to the project?*

Contractor

Business Owner

Owner/Contractor

Name of Building Contractor*

Name of Owner*

Total Completed Project Value

Do you need coverage for the existing structure?

Yes

No, coverage is for the renovation only.

Value of Existing Structure

Project Location

Address

Street Address City State ZIP Code

Mailing Address

Mailing Address

Street Address City State ZIP Code

Any other projects anticipated in the next calendar year?*

Yes

No

Are there or will there be any additional structures on the property?*

Yes

No

Are you within 1000 feet of a fire hydrant or water supply?*

Yes

No

Are you within 5 miles of a fire station?*

Yes

No

Will the structure be occupied during construction?*

Yes

No

Any structural work?*

Yes

No

Year Original Structure Was Built

Check All That Apply

Work On Foundation

Shoring or Underpinning

Work on Load Bearing Walls

Elevators

Staircases

Room Addition

Number of Stories

1

2

3 or more

Square Footage (including basement)*

Construction Type

Frame

Joisted Masonry

Non-Combustible

Masonry Non-Combustible

Fire Resistive

Unknown

Anticipated Completion Date*

Month

Day

Year

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