Altamira Insurance Agency

Builders Risk / Course of Construction Application

Please complete all sections accurately. Your information is sent securely to your agent. Completion of this form does not bind coverage.

Step 1 of 8 — Insured Information 13%

Insured Information

Tell us about the named insured for this project.

Named Insured *

Mailing Address — Street *

City *

State *

Zip *

Inspection Contact for Insured — Name

Inspection Contact — Phone

Email Address *

Phone *

General Contractor Name (if different than Named Insured)

Insured is:

Owner Contractor Developer Other

Please describe

Project Description & Values

Where the project is, what it is, and the values to be insured.

Project Name *

Project Address — Street *

City *

County

State *

Zip *

Start Date *

Completion Date *

Project Type * (check all that apply)

New Construction – Ground Up Single Location Prior Start / Mid-term Risk Reporting Form Policy Includes Existing Structures Renovation/Remodel/Rehab/Interior Buildout WITHOUT structural changes Remodel with Structural Changes – Repair, Replacement or Removal of Load Bearing Walls Renovation with Historical Exposures

Please select at least one project type before continuing.

Description of project *

Please describe the project in detail. Minimum 5 words; "any" or one-word answers cannot be processed.

Please provide a more detailed description of the project (at least 5 words) before continuing.

Limits of Liability

Enter whole dollar amounts. Leave blank if not applicable.

Hard Costs $ *

Loss of Rents or Income from Delay $

Other Soft Costs $

Existing Structure (if applicable) $

Total Insured Values $

Project Details & Construction

Building counts, construction type, and site characteristics.

Number of Buildings *

Number of Stories *

Number of Units *

Total Square Footage *

Distance Between Buildings

ISO Protection Class at Site

Construction Type *

FrameWalls of wood or other combustible material, including brick/stone veneer or stucco on wood Joisted MasonryMasonry or fire-resistive exterior walls with combustible (wood) floors and roof NoncombustibleWalls, floors, and roof of metal or other noncombustible materials Masonry NoncombustibleMasonry exterior walls with noncombustible or slow-burning floors and roof Fire ResistiveWalls, floors, and roof of masonry or other fire-resistive materials rated at least two hours OtherModular, Cross Laminated Timber, or any construction not described above

Describe (e.g. Modular, Cross Laminated Timber)

Does the structure have firewalls?

Yes No

How many 2-hour (or greater) firewalls will the structure have?

Roof Type (check all that apply)

Metal Concrete Wood Shingles Composition Shingles Build-Up Clay Tile

Exterior Cladding (check all that apply)

Brick Concrete Block EIFS Glass Hardy Board Wood Tilt Up Other

Provide details of EIFS construction, type, and % of wall surface area

Are buildings transferred to permanent insurance once completed?

Yes No

Maximum Value Under Construction at Any One Time $

Has the project already started?

Yes No

Original start date

% complete at this time

Is the structure located within 1,000 feet of Tidal Water or a Barrier Island?

Yes No

Is the structure to be on pilings?

Yes No

What percentage of the structure is glass?

Is the glass impact resistant?

Yes No

Site Security & Contractor Experience

How the site is protected and who is building it.

Site Security

Fenced?

Yes No

Lighted?

Yes No

Camera System?

Yes No

Watchman?

Yes No

Hours on Duty

Other Security

Fire hydrant within 500 feet of project site?

Yes No

Contractor Experience

Name of General Contractor *

Years of Experience *

Has the contractor completed this type of project before?

Yes No

Formal Hot Works Program?

Yes No

Formal Loss Prevention Program?

Yes No

% of Job Subcontracted

Number of Projects in the last 12 months

Has the builder had any single loss of $25,000+ in the last 5 years?

Yes No

Please elaborate

Coverage Requests & Interested Parties

Coverage you'd like quoted, deductibles, and any parties to be listed on the policy.

Coverage Requests (check all that apply)

All Risks Windstorm Earth Movement Flood Occupancy Soft Costs Delay/Loss of Income Terrorism

AOP Deductible

$5,000 $10,000 $25,000 Other

Other AOP deductible

Named Storm Wind Deductible

5% 3% 2% 1% Other

Other named storm deductible

If Flood or Earth Movement is requested, what sublimit is needed? $

NFIP Coverage?

Yes No

If the site is in an SFHA flood zone, what is the estimated First Floor Elevation?

List any other required coverage

Interested Parties

Do you need to add a Loss Payee?

Yes No

Loss Payee Name

Reference/Loan Number

Street Address

City

State

Zip Code

Do you need to add a Mortgagee?

Yes No

Mortgagee Name

Reference/Loan Number

Street Address

City

State

Zip Code

Do you need to add an Additional Insured?

Yes No

Additional Insured Name

Reference/Loan Number

Street Address

City

State

Zip Code

Eligibility Questions

The following questions determine program eligibility. Please answer all questions accurately.

1. Does the project involve construction of anything other than Residential and/or Light Commercial? Residential is defined as single-family dwellings or multi-family dwellings. Light Commercial is defined as offices, retail/shopping centers, storage facilities, small/medium hotels, education (Pre-K through 12 only), and restaurants.

Yes No

2. Does the project involve mobile, modular, prefabricated assembly, construction, or renovation?

Yes No

3. Does the intended occupancy of the project involve any form of cannabis operations?

Yes No

4. Does the project involve the construction of more than one structure as part of an apartment, condominium, or townhome complex?

Yes No

5. Is the project undergoing repair and/or replacement due to prior damage on the same construction site?

Yes No

6. Is the project undergoing a repair or replacement after a catastrophic event? (e.g. wildfire, earthquake, flood, tornado, hurricane)

Yes No

7. Is the general contractor of the project in compliance with state or local licensing requirements, with a minimum of two (2) years of experience?

Yes No

8. In the last three (3) years, has the insured or contractor: had two (2) or more losses; had a single loss greater than $10,000; or had a loss ratio of more than 40%?

Yes No

9. Has the insured and/or contractor filed for bankruptcy or reorganization within the last five (5) years?

Yes No

10. Has the insured and/or contractor had a builders risk policy cancelled or non-renewed by any previous insurance carrier in the last three (3) years?

Yes No

11. Is this submission a request for extension of an expiring policy?

Yes No

12. Is this submission for builders risk coverage that is currently, or has previously been, in place with another insurance carrier?

Yes No

13. Has construction begun more than 14 days prior to the proposed inception date? (any construction past excavation/foundation)

Yes No

14. Is there a current active brush or wildfire within 50 miles of the project site?

Yes No

Renovation Addendum

Because your project includes renovation or remodel work, please complete the details below.

Renovation Details

Original Year Built

Date Purchased

Currently Occupied?

Yes No

How long vacant?

Existing Value $

Renovation Cost $

Structural Work?

Yes No

Historic Landmark?

Yes No

Date of Last Remodel/Renovation

Electrical (year)

Plumbing (year)

Other (describe)

Year roof replaced?

Any aluminum wiring present?

Yes No

Any Section 8 rental occupancy?

Yes No

Will units be occupied during renovation?

Yes No

Intended occupancy at completion of renovation

Protection

Systems operational during renovation?

Yes No

Automatic Sprinkler System?

Yes No

Burglar Alarm?

Yes No

Are systems monitored?

Yes No

Central Station?

Yes No

Has the structure sustained damage or loss?

Yes No

Provide details (date, cause, damage estimate)

Description of Renovation / Scope of Work *

Please describe the renovation scope in detail. Minimum 5 words.

Please provide a more detailed scope of work (at least 5 words) before continuing.

Signature & Agreement

Please read the statement below and sign to complete your application.

This Application is the basis for coverage; therefore, any incorrect or incomplete statements or answers could nullify coverage. Completion of this form neither binds coverage nor guarantees that a policy will be issued.

I hereby request that my application for insurance coverage be submitted for consideration. I authorize any person or organization to release information that may relate to my insurability.

I hereby indicate that the aforementioned statements and answers are correct and complete. I understand that an incorrect or incomplete statement could void my protection.

FRAUD WARNING:

Any person knowingly and with intent to defraud any insurance company who files an application for insurance with false or misleading information or who conceals, for the purpose of misleading any insurance company or other person as to material facts contained in this application, commits a fraudulent insurance act which is a crime and may subject person to criminal or other penalties of certain municipal jurisdictions and may result in denial of benefits that might otherwise be due under a contract of insurance issued by an insurance company based on representations contained in this application.

Signature * (type your full legal name)

Printed Name *

Title / Position *

Date *

There was an error submitting your application. Please try again or call us at (435) 272-8042.

Please answer all Yes/No questions highlighted in red before continuing.

Application Submitted!

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