Builders Risk Insurance Your Name* First Last Business Name (if applicable)Phone Number*Email* Project Location Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Project DetailsIs this a new construction or remodel project?*New ConstructionRemodelIs this a residential or commercial project?*ResidentialCommercialOtherHas the project already started?*YesNoProject Start Date* Date Format: MM slash DD slash YYYY Percentage Completed5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%From the beginning of the project until now, have there been any incidents or damage that may give rise to a claim?*YesNo Applicant InformationWhat is your relation to the project?*ContractorHomeownerOwner/ContractorWhat is your relation to the project?*ContractorBusiness OwnerOwner/ContractorName of Building Contractor*Name of Owner* Total Completed Project ValueDo you need coverage for the existing structure?YesNo, coverage is for the renovation only.Value of Existing Structure Mailing AddressMailing Address Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Any other projects anticipated in the next calendar year?*YesNoAre there or will there be any additional structures on the property?*YesNoAre you within 1000 feet of a fire hydrant or water supply?*YesNoAre you within 5 miles of a fire station?*YesNoWill the structure be occupied during construction?*YesNoAny structural work?*YesNoYear Original Structure Was BuiltCheck All That Apply Work On Foundation Shoring or Underpinning Work on Load Bearing Walls Elevators Staircases Room Addition Number of Stories123 or moreSquare Footage (including basement)*Construction TypeFrameJoisted MasonryNon-CombustibleMasonry Non-CombustibleFire ResistiveUnknownAnticipated Completion Date* MM DD YYYY Questions? Call 800-311-3081
