Fillable GROUND UP COURSE OF CONSTRUCTION APPLICATION FORM (Abram Interstate Insurance)

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GROUND UP COURSE OF CONSTRUCTION APPLICATION FORM (Abram Interstate Insurance)

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ATR – 127 Ground Up Course of Construction Application Page 1 of 3
GROUND UP COURSE OF CONSTRUCTION APPLICATION FORM
THE ANSW ERS TO THESE QUESTIONS FORM PART OF AN APPLICATION FOR INSURANCE ONLY. NOTHING IN THIS APPLICATION
SHALL BE DEEMED AN AGREEMENT TO PROVIDE INSURANCE AND UNDERW RITERS 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? Yes No
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 LQ a high crime QHLJKERXUKRRG"
9. Will the new structure exceed 3 (three) stories or 30,000 square feet? Yes No
10. Has the construction work already begun?
11. Is the new construction any of the following: being raised / elevated / lifted / placed on pilings, 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. Is the applicant acting as Contractor?
Yes No
14.
Are all relevant permits in place and is the Contractor licensed? Yes No
1. Is there a signed written contract between the applicant and the Contractor?
1. 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?
 Are there any documents providing a breakdown of the projected cost of the work?
1. Does the Contractor carry commercial general liability insurance coverage with a minimum occurence
Yes No
Yes No
Yes No
limit of $1,000,000? Yes 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
. Period of Insurance: 3 Months 6 Months 9 Months Annual. Enter Protection Class:
2. Completed Value of newly constructed building:
2. Total Square Footage of Proposed Final Structure:
2. Construction Type: Fire Resistive Frame Joisted Masonry Masonry Non Combustible Modified Fire Resistive Non Combustible
2. Number of Floors:
2. W ind Hail Deductible per occurrence: $1,000 $2,500 5,0007,50010,00015,00025,000
2. All Other Perils Deductible: $1,000  $2,505,0007,50010,00015,00025,000
. Type of Quote: %asic6pecial
. Estimated Renovation or Construction W ork Project Costs:
. Description of New Construction W orks:
3. W hat is the CGL Limit carried by the Contractor:
300k 500k 1m
3. Is Vandalism
and Malicious Mischief cover required:
Yes No 'R\RXZLVKWREX\FRYHUDJHIRU7KHIWRI%XLOGLQJ0DWHULDOV<HV1R
3. Is TRIPRA coverage required:
Yes No
3. Please select type of Security at Location to be insured: Fenced and/or Gated Guarded Automatic Sprinkler System
Active Central Station Fire Alarm Active Central Station Burglar Alarm Lighting on property location None
3. Have there been any insured or uninsured losses or claims at the property to be insured: Yes1o
Describe all prior losses or claims including the date, the nature or occurrence, the status, the amount, and whether the damage has been
repaired:
3. Prior use of Land, when last occupied:
3. If required, please enter details of Additional Insured:
________________________________
ATR – 127 Ground Up Course of Construction Application Page 3 of 3
DECLA5$TION
THE ANSW ERS GIVEN IN THIS APPLICATION ARE CORRECT TO THE BEST OF MY KNOW LEDGE. I UNDERSTAND THAT THESE
ANSW ERS 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 A
ND VA, INSURANCE BENEFITS MAY ALSO BE DENIED.
Applicant’s Signature
Retail Broker’s Signature
Date
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GROUND UP COURSE OF CONSTRUCTION APPLICATION FORM (Abram Interstate Insurance)

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Completed 10 July 2021

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