X/TwitterThis field is for validation purposes and should be left unchanged.Applicant InformationApplicant Entity Type:(Required) Individual Partnership Corporation LLC Joint Venture Trust Other Applicant Name:(Required)Applicant's Full Name(Required) First Last Applicant's Company Name:(Required)(N/A if you don't have one)Owner's Full Name(Required) First Last Construction Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Construction Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is business address same as mailing address?(Required) Yes No Is construction address same as mailing address?(Required) Yes No Mailing Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(Required)FaxEmail Address(Required) Website FEIN (Tax ID #):(Required)Does the applicant have a DBA (Doing Business As) name:In what year did the applicant start operations?(Required)Please describe the applicant's day-to-day business operations:(Required)Main area of practice, type of services provided, products, etc. - Please be detailedAre there any locations or business interests that are owned by the applicant but not shown on the application?(Required) Yes No Are there high-valued goods, including merchandise at your location?(Required) Yes No If yes, what is the approximate value of your inventory?(Required)What is the value of your business personal property?(Required)(BPP are all your furniture, computers, printers, etc. Basically, anything you will take with you if you move)Annual Gross Revenue:(Required)Annual Gross Income:(Required)Contractor License:(Required)State(s) / Area of Operation:(Required)Licensed for Business in State(s):(Required)Is applicant or any proposed named insured one of the following? (Check all that apply)(Required) Construction Consultant Construction Manager Developer General Contractor Subcontractor Spec Builder Architect/Engineer Surveyor Does the applicant currently own or operate any other business?(Required) Yes No If yes, list name and describe operations and percentage of ownership:(Required)Construction InformationProject NameType of Construction(Required) New Construction Renovation Remodel Addition Type of Building(Required) Residential Commercial Industrial Mixed-Use Number of Stories:(Required)Please enter a number from 1 to 99.Total Square Footage:(Required)Please enter a number from 0 to 99999.Estimated Project Value:(Required)Please enter a number from 0 to 9999999.Project Start Date:(Required) MM slash DD slash YYYY Expected Completion Date:(Required) MM slash DD slash YYYY Who Owns the Property?(Required) Owner Contractor Developer Other Who is the General Contractor?(Required)NameLicense NumberExperience (Years)Contact InfoWill any subcontractors be used?(Required) Yes No If yes, are they required to carry insurance?(Required) Yes No Is this a ground-up construction project?(Required) Yes No If no, describe existing structure and modifications being made:(Required)Will the building be occupied during construction?(Required) Yes No Do you have all necessary permits for this project(Required) Yes No Requested Coverage DetailsRequested Coverage LimitsBuilding / Structure:(Required)Please enter a number from 0 to 9999999.Soft Costs:(Required)Please enter a number from 0 to 999999.Debris Removal:(Required)Please enter a number from 0 to 999999.Temporary Structures:(Required)Please enter a number from 0 to 999999.Equipment & Tools:(Required)Please enter a number from 0 to 999999.Requested Deductible Amount:(Required) $1,000 $2,000 $5,000 Other Do you require coverage for:(Required) Materials in transit? Materials stored off-site? Soft costs (e.g., permits, fees, legal expenses)? Equipment breakdown? Flood or earthquake damage? Theft or vandalism? Select AllDo you employ temporary, volunteer, casual workers or uninsured subcontractors?(Required) Yes No If yes, please describe:(Required)Will subcontractors be required to carry their own insurance?(Required) Yes No Will there be any hazardous activities on-site? (e.g., blasting, demolition, excavation)(Required) Yes No If yes, please describe:(Required)Who should be listed as additional insureds?(Required)Risk Management & Safety MeasuresDoes your safety program contain the following written procedures? Please check all that apply:(Required) Safety rules & regulations Safety meetings Site safety inspections Fall protection requirements Substance abuse prevention Accident investigation / reporting Fall protection requirements Fire / Protection training Hazardous material handling No Safety Procedures Enforced Unsure Select AllDoes the applicant have a formal safety program in place?(Required) Yes No Do you require workers to wear personal protective equipment (PPE)?(Required) Yes No Does the applicant offer an orientation/training program for new or transferred employees?(Required) Yes No What security measures will be in place at the construction site?(Required) Fencing Surveillance Cameras Security Guards Locked Storage for Materials Other Please list other:(Required)What weather protection measures will be in place?(Required) Storm Covers Drainage Systems Flood Barriers Other Please describe other:(Required)Insurance History & Claims InformationDo you currently have builder’s risk insurance?(Required) Yes No If yes, name of current insurer:(Required)Policy expiration date(Required) MM slash DD slash YYYY Current coverage limit:(Required)Please enter a number from 0 to 999999.Have you had any builder’s risk claims in the past five years?(Required) Yes No If yes, please provide details (date, type of claim, amount paid):(Required)Has the applicant ever had insurance coverage canceled or non-renewed?(Required) Yes No If yes, please explain:(Required)Additional Comments or Special Considerations(Please provide any other relevant information that may impact your insurance coverage needs.) 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