Part 1 – Insured Information
Insured Name:
Mailing Address:
Contact Name:
Form of Business
(Check One):
Corporation Joint Venture
Business Description
(Check One):
Part 2 – Builder Information
Is the Builder's name different than the named insured?
If Yes, Does the Builder need to be named as Additional Insured?
Enter the Builders Name
How many years’ experience does the Builder have?
Number of structures built/remodeled in the past 12 months:
Number of structures projected for the next 12 months:
Has the builder/contractor had a single loss over $10,000 in the last 3 years?
(Include Insured & Uninsured Losses)
Part 3 – Policy Information
Policy Effective Date:
Type of Project: New Construction
Remodeling/Renovation Excluding Coverage for the
Existing Structure
Remodeling/Renovation Including Coverage for the
Existing Structure
Type of Property: Residential (1-4 Single Family Dwellings)
Policy Period: 1 Year from Effective Date
6 Months from Effective Date
9 Months from Effective Date
Building Value:
Part 4 – Policy Information
Property Address:
Property City:
Property County:
Is the Contractor insuring any other buildings with Zurich within 100ft of this structure?
If Yes, please provide total estimated completed value of all structures under
construction within 100ft and insured with Zurich, Including this one.
Construction Material:
Joisted Masonry Non-Combustible
Masonry Non-Combustible Fire Resistive
Protection Class:
Part 4 – Policy Information (Continued)
Start/Completion Date: to
# of Stories:
Square Footage:
Roof Material:
Will Structure be occupied during construction?
If yes, by whom?
Part 5 – Project Information
Has the project started? Yes No
If yes, date started:
Percent completed:
If no, will renovations begin within 60 days of the policy effective date?
Is there a sales contract on this structure? Yes No
Estimated length of project in months
Scope of Work: Remodel – Remodeling of interior finishes; replacement of
interior fixtures, cabinets, flooring, etc. No changes to the
exterior or structure.
Remodel/Minor Structural – Remodel work as listed above
and minor changes to exterior (doors, windows, skylights,
exterior painting), roof replacement, ground floor additions
and all non- structural changes such as HVAC, plumbing and
Restructuring – Repair, replace, remove load bearing walls.
Adding additional stories, adding stairways or elevators.
Foundation work such as underpinning and/or dewatering.
Description of work to be performed:
Part 6 - Coverage Information
Any coverage for development/subdivisions fences, walls or signs: Yes No
If yes, please enter coverage amount:
Do you want to exclude wind coverage: Yes No
Eligible for the wind pool: Yes No
If yes, will wind coverage be purchased through the wind pool: Yes No
What limit can be purchased:
Flood coverage: Yes No (Must be declined by National Flood Program)
Modular Information
(Only complete if structure is modular)
Who provides transit coverage:
How are homes transported to job:
Estimated time to complete each structure:
Does the manufacture put the four sides together and let the builder finish it off?
Yes No
Manufacturer website:
Apartment Occupancy
(Only complete if occupied as apartments)
Number of buildings:
Number of units per building:
Value per building:
Distance between buildings:
Total projected completed value:
Will the structure be occupied during construction: Yes No
Part 7 – Windstorm Information
Is the structure located within 1,000 feet of tidal water or located on a barrier island:
Yes No
Is the building being constructed on pilings: Yes No
If yes, enter the piling depth in feet:
Percent complete by November 1:
When will the building be capped:
(Reach its highest point)
When will the building be fully enclosed:
What percentage of the structure is glass:
Is the glass impact resistant: Yes No
Where and how will materials be stored:
What preventative measures are taken to mitigate losses from windstorm?
Is location shielded by hills, buildings, or any type of wind block?
Part 8 – Renovation Information
Amount of Renovation/improvements:
Amount of existing building or structure:
Total completed value of all covered property:
Will the existing structure be insured by another policy during the construction:
Yes No
Year built (existing structure):
Does the building have an operable sprinkler system: Yes No
Part 8 – Renovation Information (Continued)
When was the heating system last updated:
When was the electrical system last updated:
Purchase price of shell?
Is the existing structure listed on any historical registry or subject to a historical society
Has the existing structure been moved or will it be moved as part of this project:
Yes No
Date existing structure was purchased:
Any previous losses at this location as a result of quake, flood, wind, fire or vandalism:
Yes No
If yes, explain all losses including the peril involved, amount of loss and the date of the
Provide a brief description of the structure to be renovated and condition of the
existing structure: