Fillable BUILDERS RISK SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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BUILDERS RISK SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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  • 49 check-boxes
  • 133 other fields

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Page 1 of 5
BUILDERS RISK – SUPPLEMENTAL APPLICATION
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
New Venture?
Yes No
Renewal?
Yes No
Policy Number:
Current Effective Date:
Current Expiry Date:
Requested Effective Date:
Requested Expiry Date:
Website:
2) Current Carrier Information:
Expiry Date:
Yes No
Please attach copies of the following:
a) Currently valued five-year loss runs, including complete claim details for all losses
b) Applicant’s description of operations, brochure, or marketing materials if a website is not available
3) Mailing Address:
City: State: Zip Code:
4) Property Address:
City: State: Zip Code:
5) Are you a(n): Corporation Individual Partnership Municipality For Profit
Joint Venture Other:
6) How long have you been in operation under this business name or any others (please provide any prior entities or
additional entities/DBAs to be covered)?
7) What is your interest in this project?
Owner Contractor Owner and Contractor Other:
I. GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
8) Construction Start Date:
9) Construction Projected End Date:
10) Has any construction work already started? Yes No
a. If yes, has prior coverage been in place? Yes No
b. If yes to 10) and no to a., please attach an explanation.
c. What percentage of work is completed? %
11) What coverage(s) are you requesting? Check and provide requested limits for all that apply:
Business Income w/Extra Expense $ Mechanical Breakdown & Testing $
Property in Transit $ Property in Storage $
Earth Movement $ Flood $
Other: $
12) Please complete the following table for your receipts and payroll:
Revenue
Payroll
Projected Year
Last 12 Months
2nd Prior Year
13) If you are not the contractor or owner/contractor, please list the contractor:
a. How many years of experience does this contractor have?
14) Is the property being renovated? If yes, please complete section III: RENOVATION. Yes No
a. If no, is the building work being performed ground up? Yes No
b. If no to 13) and a., please explain:
c. If yes to a., what is the total insurable value of building materials (assume 100% coinsurance)? $
15) Briefly describe the work being performed:
16) What is the intended occupancy after work is completed?
17) What is the building construction material?
Frame Joisted Masonry Non-Combustible Masonry Non-Combustible
Fire-Resistive Other:
18) Number of stories:
a. Does any work involve tandem crane lifts or tower cranes? Yes No
19) Roofing materials:
20) Protection class:
21) Will any portion of the structure be occupied prior to completion of the project? Yes No
a. If yes, by whom?
b. Please attach details about the occupancy and how construction area access is restricted.
II. PROPERTY DETAILS
Page 3 of 5
22) Is the project site:
a. Fenced? Yes No
b. Lighted? Yes No
c. Locked? Yes No
d. Security guards or night watchmen? Yes No
d. Other security: Yes No
23) Does the project include any demolition of existing structure(s)? Yes No
24) Does the project include any structural, frame, or foundation alterations? Yes No
25) Does the building have any existing damage? Yes No
a. If yes, please clarify:
26) Are you seeking coverage for the existing structure? Yes No
a. If no, is the structure covered under another property insurance policy? Yes No
b. What is the total insurable value of the following (based on completed value and 100% coinsurance):
+ Existing Structure: $
+ Building Materials: $
+ TOTAL: $
27) What year was the existing structure built?
28) What is the square footage of the original building?
29) If the project includes any addition, what will the new square footage be?
30) What was the previous occupancy of the structure(s)?
31) What current fire safety systems are installed in the structure? Check all that apply:
Central Alarms Local Alarms Automatic Sprinklers Automatic Suppressants
Manual Extinguishers Other:
a. Are all of the above checked in working order? Yes No
b. Will these systems be maintained and operable for the duration of construction? Yes No
c. If no to a. or b., please attach an explanation and describe fire prevention measures taken.
32) Will electrical service be maintained? Yes No
a. When was the electrical system last updated?
33) Will heating service (gas, oil, etc.) be maintained? Yes No
a. When was heating/HVAC equipment last updated?
34) Will water service be shut off and pipes drained/winterized? Yes No
a. When was the plumbing last updated?
35) Does the current structure have a burglar or intrusion alarm in place? Yes No
a. If yes, will this be maintained during construction? Yes No
III.RENOVATION (complete only if the property is being renovated)
Page 4 of 5
36) Do you know of any incidents not currently reported to insurance that may result in a claim Yes No
against you? If yes, please attach an explanation.
37) During the past five years, has any insurer ever canceled or non-renewed similar insurance Yes No
to any applicant or has your insurance been canceled for nonpayment of premium by any
insurance or finance company? If yes, please attach an explanation.
38) Claim Details (duplicate this page for all claims):
a. What was the date of the incident?
b. What line(s) of your coverage(s) was this claim reported on? Check all that apply:
Builders Risk Property in Transit Property in Storage
Mechanical Breakdown Other Commercial Property Business Income/Extra Expense
Commercial General Liability Pollution Legal Liability Other:
c. Please describe the circumstances leading up to the claim, the factual details of the incident, the value of
materials lost or damage to structure, and steps taken following the incident to mitigate loss and evaluate the
claim. Please note “attached” and include an additional sheet if the details do not fit below:
d. If this claim is closed, did it require trial or arbitration to settle? Yes No
e. If this claim is open, do you anticipate it going to trial or arbitration? Yes No
+ If yes, when?
f. Were any of your procedures or rules changed after this incident? Yes No
g. Was the structure or materials a total loss/full insured value claimed? Yes No
+ If no, what percentage was lost? %
h. Total claimed: $
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, any person who knowingly, and with intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
IV. CLAIMS HISTORY
Page 5 of 5
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an application for
insurance or statement of claim 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a claim 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 civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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BUILDERS RISK SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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