Fillable High Value Home Builders Risk Application

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High Value Home Builders Risk Application

On average this form takes 23 minutes to complete

The High Value Home Builders Risk Application form is 4 pages long and contains:

  • 2 signatures
  • 49 check-boxes
  • 61 other fields

Country of origin: CANADA
File type: PDF

BROWSE OTHERS (CANADA) FORMS

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1550 Bedford Highway, Suite 815 Bedford, NS B4A 1E6
t: 1-877-343-8224 f: 1-877-432-9822 e: accounts@agileuw.ca
agileuw.ca
Page 1 of 4
Agile Underwriting Solutions is a trademark of Underwriting Contract Administrators (2014) Inc.
High Value Home – Builder’s Risk Application
1. Project Type: :
New Construction
Other ___________________________
2. Legal name of Applicant: ___________________________________________________________________________
3. Address: ________________________________________________________________________________________
4. Legal Name of General Contractor: ___________________________________________________________________
5. Legal Name of Dwelling Owner: ______________________________________________________________________
6. Occupancy when completed:
Single Family Dwelling
Primary Residence
Seasonal
Secondary
7. Loss payable: ____________________________________________________________________________________
8. Address of project site: _____________________________________________________________________________
9. Geo-technical report completed?
Yes
If yes, please attach.
10. Will project be constructed in compliance with geotechnical recommendations?
If modified, please provide details.
11. Nature of Ground:
12. Soil:
13. Public fire protection:
14. Site Fenced: Height/Type: ___________________________
15. Patrol Service Hrs/Rounds: ___________________________
16. Video Surveillance: Type: ___________________________
17. Lighting:
18. Alarms – Intrusion:
Yes
No
With modifications
Flat
Hillside
Hilly
Swampy
Other
Shale
Rock
Filled Ground
Other ___________________________________
Within 300m fire hydrant
Within 8kms firehall
Unprotected
General Information
Additional Protections
Page 2 of 4
Agile Underwriting Solutions is a trademark of Underwriting Contract Administrators (2014) Inc.
19. Fire/smoke: Alarm sounds to _________________________________________________________________
20. Other: describe ___________________________________________________________________________________
________________________________________________________________________________________________
21. Standpipe and hose system Portable fire extinguisher(s) Sprinkler system
Hot work permit system Private hydrants
22. Describe precautions, if any, to prevent Windstorm, Ice and/or Sleet damage to the project. ______________________
________________________________________________________________________________________________
________________________________________________________________________________________________
23. Adjacent structures – type of construction, occupancy and distance: __________________________________________
________________________________________________________________________________________________
24. Daily clean-up program?
Yes
25. Refuse burned on site?
Yes
26. Winter heating conditions (type of heaters): _____________________________________________________________
27. Detail use of any flammable liquids, gases or explosives – materials to be present on site. ________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
28. Any use of the following?
Plastic weather enclosures Tarpaulins Straw Scaffolding
Wood boarding Cranes
29. # of Storeys: ________________ Total area: ___________________ sq ft sq metres
30. Type of foundation: ______________________________________________________________________________
31. Construction materials – standard construction
32. Exterior walls:_____________________________________________________________________________________
33. Framework: ______________________________________________________________________________________
34. Roof: Structure: ______________________________________ Covering: ______________________________
35. Floors: Structure: _____________________________________ Covering: ______________________________
36. Type of insulation: _________________________________________________________________________________
37. Any special features – such as stained glass, glass curtain walls, artwork to be incorporated, if so describe ___________
________________________________________________________________________________________________
________________________________________________________________________________________________
Project Details
Page 3 of 4
Agile Underwriting Solutions is a trademark of Underwriting Contract Administrators (2014) Inc.
38. Completed contract price: ___________________________________________________________________________
39. Premises personal liability: $1,000,000 $2,000,000 $5,000,000
40. Deductible desired: $1,000 (standard) $2,500 $5,000 $10,000 $25,000
41. Earthquake coverage:
Yes
42. Deductible: 5% 10%
43. Effective date: _________________________________ Completion date: _________________________________
44. Actual start date: _________________________________
45. Percentage of work subcontracted? _________________________________
46. Certificates of insurance required for sub-contractors?
Yes
Limit $ _________________________________
Underwriters will rely upon each and every response given in this Proposal Form and any Supplementary Proposal Form in
deciding whether or not to insure this risk and if so at what premium, terms and conditions. Underwriters regard every
response to be material to their decisions. Failing to answer or answering any question below incorrectly could invalidate any
policy of insurance written by Underwriters for this risk. We have a professional duty of confidentiality and are committed to
holding personal information in strict confidence. The information provided to us will only be disclosed where required by law
to do so or required to do so in conducting negotiations with third parties, such as insurance companies, on your behalf. We
will further safeguard the security of such information in a manner appropriate to sensitivity of that information.
Each and every question must be answered by the broker and/or account executive.
Is this account NEW to your office?
Did you receive order direct from the Applicant?
If no, how long have you known the applicant? __________
Do you recommend this applicant in every respect?
Do you handle other insurance for the Applicant?
Note: I/We hereby declare that the statements and particulars contained in this application are true and that I/we have not
suppressed or misstated any material facts and I/we agree that should a policy be issued then this application shall be the
basis of the contract with Underwriters. This application must be signed by the Producer/Account Executive.
Yes
Yes
Yes
Yes
Broker Declaration
Contract Period
Total Insured Value
Page 4 of 4
Agile Underwriting Solutions is a trademark of Underwriting Contract Administrators (2014) Inc.
Date: _________________ Signature of Producer/Account Executive: ______________________________
Print Name of Brokerage: ______________________________________________________________________________
Print Name of Broker/Producer: _________________________________________________________________________
Address of Brokerage: ________________________________________________________________________________
PLEASE REVIEW CAREFULLY
Consumer and previous insurer reports containing personal credit, factual or investigative information about the applicant
may be sought in connection with this application for insurance or a renewal, extension or variation of the insurance applied
for.
I hereby make application for insurance on the above charges, items of property, subject to the Statutory Conditions,
Stipulations Warranties, Exclusions, Limitations, Conditions, and Definitions as contained in the policy or endorsed thereon.
THE STATEMENTS MADE IN THIS APPLICATION ARE TRUE AND CORRECT.
Date _____________________________ Signature of Applicant ___________________________________
Applicant Signature
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High Value Home Builders Risk Application

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Completed 25 March 2022

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