Fillable *5281'83COURSE OF CONSTRUCTION APPLICATION FORM (Risk Placement Services, Inc.)

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*5281'83COURSE OF CONSTRUCTION APPLICATION FORM (Risk Placement Services, Inc.)

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ATR – 127 Ground Up Course of Construction Application Page 1 of 3
*5281'83COURSE OF CONSTRUCTION APPLICATION FORM
THE ANSWERS TO THESE QUESTIONS FORM PART OF AN APPLICATION FOR INSURANCE ONLY. NOTHING IN THIS APPLICATION
SHALL BE DEEMED AN AGREEMENT TO PROVIDE INSURANCE AND UNDERWRITERS MAY DECLINE TO OFFER COVERAGE OR
OFFER COVERAGE ON TERMS THAT DIFFER FROM THE COVERAGE SOUGHT BY THE APPLICANT.
ELIGIBILITY QUESTIONS
1. In which state is the property to be insured:
2. Please confirm the type of property to be insured: Residential Commercial Farm Other
3. Has the applicant had any policy of property insurance cancelled or non-renewed in the past
3 (three) years for reasons other than vacancy?
4. Has the applicant been convicted of the crimes of arson or insurance fraud?
5. Is the applicant currently involved in bankruptcy proceedings?
6. Is the land on which new construction is taking place subject to any tax or mortgage liens?
7. Is the new construction to be insured subject to more than 2 (two) mortgages or
other encumbrances or a mortgage provided by an individual or entity other than a
financial institution?
8. Is the new construction located in Protection Class 9 or 10 or located in a high crime
neighbourhood?
9. Does the
existing structure exceed 3 (three) stories or 30,000 square feet?
10. Has the construction work already begun?
11. Is the new construction any of the following: modular, manufactured or mobile homes, earth homes,
dome homes, open pier, stilt homes, row or town homes, unique, green or experimental or any other non
conventional building?
12. Does the constuction work involve any of the following: demolition or underpinning of an existing
building or structure, lead, asbestos or other pollutant abatement?
13. Will the new construction site to be insured remain locked & secured against unauthorized entry throughout
the policy period when unattended?
14. Is the applicant acting as Contractor?
15.
Are all relevant permits in place and is the Contractor licensed
?
16. Has the Contractor had a minimum of 3 (three) years experience with similar renovation / remodelling /
construction work?
17. Has the Contractor been subject to more than 2 (two) insurance claims, a single insurance claim exceeding
$10,000 or any litigation in the last 3 (three) years arising from or related to its renovation or construction work?
18. Will the construction work be supervised onsite by the Contractor during the whole of the project?
19. Is there a signed written contract between the applicant and the Contractor?
20. Are there any agreements (including but not limited to hold harmless, waivers of subrogation or any other
contractual provision) in place which would relieve any contractors or workers on the project from liability?
21. Are there any documents providing a breakdown of the projected cost of the work?
22. Does the Contractor carry commercial general liability insurance coverage with a minimum occurence
limit of $1,000,000?
Yes Y No
ATR – 127 Ground Up Course of Construction Application Page 2 of 3
APPLICANT DETAILS
Name and Mailing Address of Applicant:
State
Zip code
Telephone
Email
Address of Property to be Insured:
State
Zip code
Name and Address of Retail Broker:
State
Zip code
CONTACT DETAILS
Contact Name
Telephone
Email
COVERAGE AND PROPERTY DETAILS
23. Period of Insurance: 3 Months 6 Months 9 Months Annual 24. Enter Protection Class:
25. Completed Value of newly constructed building:
26. Total Square Footage of Proposed Final Structure:
27. Construction Type: Fire Resistive Frame Joisted Masonry Masonry Non Combustible Modified Fire Resistive Non Combustible
28. Number of Floors:
29. Wind Hail Deductible per occurrence: $1,000 $2,500 $5,000 $7,500 $10,000 $15,000 $25,000
30. All Other Perils Deductible: $1,000 $2,500 $5,000 $7,500 $10,000 $15,000 $25,000
31. Type of Quote: Basic Special
32. Estimated Project Start Date:
33. Estimated Project Finish Date:
34. Estimated Renovation or Construction Work Project Costs:
35. Description of New Construction Works:
36. What is the CGL Limit carried by the Contractor:
300k
500k
1m
37. Is Vandalism and Malicious Mischief cover required:
Yes No
38. Is TRIPRA coverage required:
Yes No
39. Please select type of Security at Location to be insured: Fenced and/or Gated Guarded Automatic Sprinkler System
Active Central Station Fire Alarm Active Central Station Burglar A
larm Lighting on property location None
40. Have there been any insured or uninsured losses or claims at the property to be insured: Yes No
Describe all prior losses or claims including the date, the nature or occurrence, the status, the amount, and whether the damage has been
repaired:
41. Prior use of Land, when last occupied:
ATR – 127 Ground Up Course of Construction Application Page 3 of 3
COVERAGE AND PROPERTY DETAILS (continued)
42. Please provide name and address of Contractor responsible for the new construction:
43. If required, please enter details of Additional Insured:
DECLARATION
THE ANSWERS GIVEN IN THIS APPLICATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THESE
ANSWERS WILL FORM PART OF A POLICY THAT IS SUBSEQUENTLY OFFERED. I ALSO UNDERSTAND THAT ANY FALSE STATEMENT
MAY VOID THE INSURANCE IN ITS ENTIRETY OR RESULT IN A CLAIM BEING DENIED.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH,
OK, OR, VT FOR WHICH SEE ATTACHED). IN DC, LA, M
E, TN AND VA, INSURANCE BENE
FITS MAY ALSO BE DENIED.
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Retail Broker’s Signature
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*5281'83COURSE OF CONSTRUCTION APPLICATION FORM (Risk Placement Services, Inc.)

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Completed 30 July 2020

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