Fillable BUILDERS RENOVATIONS APPLICATION FORM (RT Specialty)

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BUILDERS RENOVATIONS APPLICATION FORM (RT Specialty)

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BUILDERS RENOVATIONS 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.
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? Yes No
5. Is the applicant currently involved in bankruptcy proceedings?
6. Is the property to be insured subject to mortgage foreclosure proceedings or tax liens?
7. Is the property to be insured subject to more than 2 (two) mortgages or other cumbrances or a mortgage
provided by an individual or entity other than a financial institution?
8. Is the property to be insured condemned, scheduled for demolition, located in Protection Class 9 or 10
or located in a high crime neighbourhood?
9. Does the existing structure exceed 3 (three) stories or involve adding a storey to the existing structure?
10. Has the renovation / remodelling / construction work already begun? Yes No
11. Is the property to be insured 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 any work involve any of the following: renovation after fire, theft or vandalism, extensive
gutting, demolition or underpinning of an existing building or structure, lead, asbestos or other pollutant abatement?
13. Is the property to be insured over 75 years old or recognized as an historical building?
14. Will the property to be insured remain locked & secured against unauthorized entry throughout the policy
period when building is unattended? Yes No
15. Does the property to be insured include knob and tube wiring or aluminium wiring or fuses? Yes No
16. Is replacing the knob and tube wiring or fuses with new wiring and circuit breakers included within project? Yes No
17. Is the applicant acting as Contractor? Yes No
18. Are all relevant permits in place and is the Contractor licensed? Yes No
19. Has the Contractor had a minimum of 3 (three) years experience with similar renovation / remodelling /
construction work? Yes No
20. 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?
Yes No
21. Does the project involve structural work or structural repairs or is the renovation/remodelling costs more than 50%
of the existing structure value? Yes No
22. Is there a signed written contract between the applicant and Contractor? Yes No
23. 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? Yes No
24. Are there any documents providing a breakdown of the projected cost of the work? Yes No
25. Does the Contractor carry Commercial General Liability insurance coverage with a minimum occurence
limit of $1,000,000? Yes No
ATR – 126 Builders Renovations Application Page 1 of 3
Submit Application
ATR – 126 Builders Renovations 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
26. Period of Insurance: 3 Months 6 Months 9 Months Annual 27. Enter Protection Class:
28. Value of Existing Structure:
29. Total Square Footage of Proposed Final Structure:
30. Construction Type: Fire Resistive Frame Joisted Masonry Masonry Non Combustible Modified Fire Resistive Non Combustible
31. Age of Building: 0-25 Years 26-50 Years 51-75 Years
32. Are there any Other Structures to be insured: Yes No 33. Value of Other Structure(s):
34. Brief Description of Other Structure:
35. Do you require Personal Property: Yes No 36. Value of Personal Property:
37. Number of Floors:
38. W ind Hail Deductible per occurrence: $1,000 $2,500 $5,000 $7,500 $10,000 $15,000 $25,000
39. All Other Perils Deductible: $1,000 $2,500 $5,000 $7,500 $10,000 $15,000 $25,000
40. Type of Quote: DP1 DP3
41. Estimated Project Start Date:
42. Estimated Project Finish Date:
43. Estimated Renovation or Construction W ork Project Costs:
44. Description of New Renovation or Construction W orks:
45. W hat CGL Limit carried by the Contractor: 300k 500k 1m
46. Is Vandalism and Malicious Mischief cover required: Yes No
47. Premises Liability: Yes No
48. Premises Liability Limits: $25,000 $50,000 $100,000 $300,000 $500,000 $1,000,000
49. How often is the building to be insured inspected by the applicant or the applicant’s representative:
Daily Weekly Monthly Other Living Onsite
50. W hich Utilities are operational: Electric Only W ater Only Electric and W ater None
51. Please select type of Security at Location to be insured:Fenced and/or Gated Automatic Sprinkler System Guarded
Active Central Station Fire Alarm Active Central Station Burglar System Lighting on Property Location None
52. 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:
ATR – 126 Builders Renovations Application Page 3 of 3
COVERAGE AND PROPERTY DETAILS (continued)
53. Describe the
type of work
to be performed during the policy period:
Replacing bathroom fixtures Replacing kitchen cabinets/furnishing Replacing plumbing/electrical or heating Interior painting
Exterior painting Replacing exterior windows or doors Removing/replacing/adding load bearing walls Replacing roof shingles
Extension to building Other
If ‘Other’, please describe the type of work:
54. Please provide name and address of Contractor responsible for the new construction:
55. If required, please enter details of Additional Insured:
DECLARATION
THE ANSW ERS GIVEN IN THIS APPLICATION ARE CORRECT TO THE BEST OF MY KNOW LEDGE. I UNDERSTAND THAT THESE
ANSWERS W ILL 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 W HO KNOW INGLY AND W ITH 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, W HICH 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 W HICH SEE AT
TACHED). IN DC, LA, ME, TN AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED.
Applicant’s Signature
Retail Broker’s Signature
Date
Date
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BUILDERS RENOVATIONS APPLICATION FORM (RT Specialty)

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Completed 13 December 2020

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