Builders Risk Insurance Picture adobe iconCoverage Comparison
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For California residents only.

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Customer Information
Named Insured
E-mail
Mailing address
City
County
State
Zip Code
Home Phone
Work Phone
FAX
Website
Applicant is :  Individual   Partnership   Corporation   Joint Venture  
Business Description:  General Contractor  Homebuilder  Remodeler
Contact Person
Contractor's # of yrs experience

Property to be Insured:
Property Address
City
County
State
ZipCode
Completed Value Amount
Per Structure		 $
Completed Value Amount
Per Project Site		 $
Name & Address
of Additional Insured
Is the Builder's name different that the named insured? Yes No
If Yes, Builder's name:

Policy Information:
Policy Effective Date
(for a 1 year period)		   
Structure Type  1-12 Family Dwelling    Commercial Structure
New or Remodel
Construction Material
Deductible Options
Any one Structure $
Property Temporarily at any other premises $
Property in Transit $
All Covered property at all locations $
Coverage for Development/Subdivision fences, walls or signs: $
Protection Town Class    1-8       9       10
Earth Movement?Yes No   Zone:     Limit $  
Water/Flood?Yes No   Zone:     Limit $  

Underwriting Information:
Yes No   Employee Training?
Yes No   Loss Prevention Program
Yes No   If remodeler, any work involving load bearing walls?
Yes No   Is coverage requested for both the existing structure and the remodeling work?
Yes No   Is this structure located within 1,000 feet of tidal water or located on a barrier island?
Yes No   Is the contractor insuring any other buildings with Zurich within 100 feet of this structure?
 1-2  3-5  6-50  Other   Number of structures built during the past 12 months
 1-2  3-5  6-50  Other   Number of structures projected for the next 12 months
Yes No   Is there a sales contract on this structure?
Yes No   Secured Sub-division?

More Underwriting Information:
Yes No   Has any interested party ever filed for bankruptcy?
  If yes, who & when?
Yes No   Any builders risk / installation losses for the past 3 years?
  What was cause of loss for any claim over $5,000
  How is this being financed?
 Mortgagee  Loss Payee

Apartments, Condominiums, or Multi-unit structures only.
(If yes, complete the following questions):
Number of Buildings
Number of units per building
Value per Building
Distance between Building

Have you any special instructions?

Reporting Method
How would you like to receive
your Builders Risk Insurance quote?		 Phone U.S.Postal E-mail Fax

 
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 Gary Jones Insurance Agency  CA License #0E22842  insure@iinsureit.com
 508 Main Street  310-615-0940 Phone  888-MY-INS-GUY
 El Segundo, CA 90245  310-615-0994 Fax  888-694-6748