Project Specific Insurance Quote Request

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Name(Required)

First Last

What is your position and role in this project?(Required)

Your entity is(Required)

Full Legal Business Name(Required)

Does your company use any DBA or Trade Names(Required)

Yes

What DBA or Trade Name(s) do you use?(Required)

Email(Required)

Phone Number(Required)

Alt Phone Number (cell, home)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Website

Date Business Started(Required)

MM slash DD slash YYYY

Project Name(Required)

Property Address of the Project(Required)

If the location address differs from your mailing address, enter the location address below.

Street Address Address Line 2 City State ZIP Code

Please provide a detailed description of the project(Required)

Project Start Date(Required)

MM slash DD slash YYYY

Projected Completion Date(Required)

MM slash DD slash YYYY

What is the source of the financing?(Required)

Is the seller of the building(s) to be covered?(Required)

Yes

N/A

Sellers are to be covered as...(Required)

Named Insured

Additional Insured

Coverage being requested(Required)

Wrap

Non-Wrap

Audit Contact

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Is the Loss Control Contact the same as the Audit contact?(Required)

Yes

Is the Loss Control Contact the same as the Administrative contact?(Required)

Yes

Loss Control Contact

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Administrative Contact

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Project Details

Any construction to involve use of EIFS (Exterior Insulation Finish System)?(Required)

Pex or Kitec piping to be used?(Required)

Has any work started at the project site?(Required)

Please provide details(Required)

What work has been started, when did it start, how much of the project has been completed?

Is it all new ground up construction?(Required)

What types of units are being built?(Required)

Single Family Dwellings

Townhouses

Condos

Commercial

Other

Please describe "other"

Single Family Dwellings

# of Units

# of Buildings

# of Stories

Construction Type

Townhouses

# of Units

# of Buildings

# of Stories

Construction Type

Condominiums

# of Units

# of Buildings

# of Stories

Construction Type

Commercial

TTL Area in Sq Ft

# of Buildings

# of Stories

Construction Type

Other

# of Units

# of Buildings

# of Stories

Construction Type

For the following: Construction Cost definition: The total cost of all work let or sublet in connection with each specific project including: the cost of all labor, materials, services and equipment furnished, used or delivered for use in the execution of the work; and all bonuses and commissions. Do not include the cost of the land, financing (including lender’s fees), insurance charges, and permit fees.

Estimated Direct Total Field Laborer Payroll (for ALL contractors) for project term(Required)

Excluding sub-contractor and supervisory costs.

Estimated total Construction Cost for project term:(Required)

Describe surrounding exposures including proximity of any adjacent structures:

North

South

East

West

Are there any exposure to hillsides, slopes, landfill or other potential subsidence areas?(Required)

Explain(Required)

Was the site previously developed?(Required)

Explain(Required)

Will the project involve any demolition of existing structures?(Required)

Explain(Required)

Is the Wrap-Up coverage to apply for demolition operations?(Required)

PROJECT TEAM – BACKGROUND/EXPERIENCE

Project Architect

Name(Required)

First Last

Phone(Required)

Email(Required)

Describe Architect’s past Residential experience:(Required)

Project General Contractor

Name(Required)

First Last

Phone(Required)

Email(Required)

Describe past Residential construction experience of the General Contractor (such as the number and types of residential structures built):(Required)

Years in business(Required)

Years building residential structures(Required)

Has the GC had any losses in the last 7 years?

GC Losses

Please add policy years starting with the most recent. Note: Incurred Losses = Expense + Paid + Reserved

Policy period

Insurer

Valuation Date

# of Claims

$ Losses Incurred

Has the insured had any Construction Defect Losses?

Construction Defect Losses(Required)

Please add policy years starting with the most recent.

Policy period

Date of Loss

$ Losses Incurred

Open/Closed

Description

Risk Management

Pre-Construction Operations

Are there any known pollution exposures on jobsite?(Required)

If yes, describe known pollution exposures on jobsite(Required)

Were there any significant design or material selection decisions made to prevent claims?(Required)

If yes, please provide specific details of such decisions?(Required)

Does the General Contractor have a formal subcontractor pre-qualification program?(Required)

If yes, please provide specific details of their program?(Required)

Please describe how you plan to address construction defect complaints from the buyers of your units throughout the state statute of repose:(Required)

Quality Control Program

Does the Named Insured have a Quality Control Program in effect to monitor all construction activities?(Required)

Who is responsible for managing the program?

Briefly describe the program and/or attach a copy of the program to this questionnaire

Does the Named Insured have a written Site Inspection Program?(Required)

Are surprise inspections conducted?

When are the inspections performed(Required)

Who determines the inspection schedule?(Required)

Who conducts the inspections?(Required)

Briefly describe the established criteria for required follow-up.(Required)

Does the Named Insured have any Independent Inspections/Assessments performed?(Required)

Who is providing this service?(Required)

What percentage of units/project are to be inspected and how often?(Required)

Briefly describe the scope of their services and/or attach a copy of their contract to this questionnaire:(Required)

Safety Program

Does the Named Insured have written safety program?(Required)

Who is designated as the safety manager on site?(Required)

Is this person on site full-time?(Required)

Does the program require that there be scaffolding and fall protection?(Required)

What height requirement is maintained?(Required)

Which does the safety program specifically address?(Required)

Security

Nuisances

Power Lines

Traffic Control

Utility Identification

Are customers and future customers or other third parties allowed on site?(Required)

What precautions are taken to protect third party visitors(Required)