Fillable Application - Builders%27s Risk Ground Up Construction36-8478

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Application - Builders%27s Risk Ground Up Construction36-8478

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BUILDER’S RISK APPLICATION: Ground-up Construction
(See separate application for Renovation and Rehabilitation projects)
(Only complete the Prior Start Construction section if applicable)
Name of Applicant:
Address:
City:
State:
Zip:
Name of Producer:
Address:
City:
State:
Zip:
Applicant is:
Individual
Partnership
Corporation
Other:
Interest of Applicant:
Owner
Contractor
Other:
Name and Address of Mortgagee:
Name:
Address:
City:
State:
Zip:
Jobsite Loss Control Contact:
E-mail Address:
Phone Number:
Risk Management Contact: ( check if same as Jobsite Contact):
Email Address:
Phone Number:
Policy Term: From:
To:
Estimated Time to Complete Project:
Describe the nature and extent of the work to be performed:
Address of Project:
SECTION I - LIMITS OF INSURANCE
1.
a.
At the project site
$
b.
In temporary storage at any location other than the project site
$
c.
While in Transit
$
d.
Extra Expense Limit ( Choose Applicable Types and limit)
$
Construction Loan Interest
$
Real Estate and Property Taxes
$
Architect, Engineering and Consultant Fees
$
Legal and Accounting Fees
$
Builder’s Risk Insurance Premium Change
$
Advertising and Promotional Expenses
$
e.
Loss of Rents Limit
$
f.
Flood Limit
$
g.
Earthquake Limit
$
2.
Is equipment breakdown coverage desired?
Yes
No
3.
Deductible:
The deductible will be determined by the chart below. If a higher deductible is desired, please indicate: $
All Construction Types
Project Size
Minimum Deductible
< $5,000,000
$5,000
> $5,000,000 up to $20,000,000
$10,000
> $20,000,000
$25,000
Builder's Risk Ground Up Construction
Page 1 of 4
© 2014 Philadelphia Consolidated Holding Corp.
09/2015
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SECTION II - CONTRACTOR
Name:
Address:
City:
State:
Zip:
1.
Has the contractor engaged in this type of project before?
Yes
No
If yes, for how many years?
2.
Contractor License Number:
3.
Contractor Website Address:
4.
Has the contractor had a loss greater than $50,000 on a project in the last 5 years?
Yes
No
If yes, please explain.
5.
Does the contractor have any judgments or suits pending?
Yes
No
6.
Has the Contractor been cited for any OSHA violations within the last 4 years?
Yes
No
If yes, explain.
7.
Does the Contractor have a written safety program in place in compliance with OSHA 29
CFR/1910?
Yes
No
If yes, please attach a copy.
8.
Does the contractor employ a designated job site risk manager?
Yes
No
If yes, how often will this site be visited?
9.
How will the jobsite be maintained from a housekeeping standpoint?
Each subcontractor is responsible for their work area(s)
Dedicated housekeeping crew(s) will be provided
10.
Will there be hot work performed on this job?
Yes
No
If yes, please provide a copy of hot work program.
11.
Are subcontractors licensed?
Yes
No
12.
Does the Contractor obtain evidence of insurance from subcontractors?
Yes
No
13.
Does the Contractor pre-qualify subcontractors?
Yes
No
If yes, explain.
SECTION III - CONSTRUCTION
Frame
Joisted Masonry
NonCombustible
Masonry NonCombustible
Fire Resistive / Modified Fire Resistive
1.
Total Square Feet:
2.
Number of floors above ground:
3.
Number of floors below ground:
4.
Is construction:
lift slab
tilt-up
prototype
modular
5.
Are pilings used?
Yes
No
6.
Is the project on filled land? (If yes, please attach geo-technical report.)
Yes
No
7.
Number of buildings:
8.
If the project value is more than $10M, attach a plot plan and construction schedule.
SECTION IV - PROTECTION
1.
Distance to operating fire hydrant: ft.
2.
Will the project site be fenced?
Yes
No
3.
Will the project site be locked?
Yes
No
4.
Will the project site be lighted?
Yes
No
5.
Will a watchman be on the premises during non working hours?
Yes
No
6.
Does the General Contractor have a written ‘no smoking’ policy?
Yes
No
If yes, please provide a copy.
7. Will the General Contractor provide operational portable fire extinguishers at strategic locations
throughout the jobsite?
Yes
No
9.
Does the project have a buyer / owner or is it being built on speculation?
Builder's Risk Ground Up Construction
Page 2 of 4
© 2014 Philadelphia Consolidated Holding Corp.
09/2015
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SECTION V – PRIOR START CONSTRUCTION
1.
Original start date of construction?
2.
a.
% of project that has been completed? %
b.
Value of portion of project that has been completed?
c.
Estimated time needed to complete project?
d.
Details of construction completed to date:
3.
Was there coverage in place prior to your request?
Yes
No
If yes, why is that coverage not being renewed or being cancelled?
4.
If no prior coverage, why the delay in placing coverage?
5.
Has there been a change in the contractor?
Yes
No
If yes, why:
6.
Have there been any losses at the project site to date?
Yes
No
If no losses, please attach a “No Loss” letter signed by the insured.
If yes, please give details of each loss.
Builder's Risk Ground Up Construction
Page 3 of 4
© 2014 Philadelphia Consolidated Holding Corp.
09/2015
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FRAUD NOTICE STATEMENTS
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 THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A
FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL
PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION).
(NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN
PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION
TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY
INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN
INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A
POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT
WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO
DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY
INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS
GUILTY OF A FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR
PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY
AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE
RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT
PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN
MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR
MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her
knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments
submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the
policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify
the Company of such changes and the Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
Produced By: (Section to be completed by Producer/Broker)
PRODUCER AGENCY
PRODUCER LICENSE NUMBER AGENCY TAXPAYER ID OR SS NUMBER
ADDRESS (STREET, CITY, STATE, ZIP)
Builder's Risk Ground Up Construction
Page 4 of 4
© 2014 Philadelphia Consolidated Holding Corp.
09/2015
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Completed 16 May 2020

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