Enter the name of your prior insurance carrier in the space provided below.

Has your request for this type of coverage been cancelled, refused, or non-renewed by any company in the past? (Missouri applicants do not need to answer this question)

Yes No

If yes, please provide the name of the company, reason for non-coverage, and date of non-coverage:

Location of Structure

Enter location of the structure in the space provided below.

Enter the name of your mortgage company (mortgagee) in the space provided below.

Please enter loss information in the space provided below.

Enter your deductible in the space provided below.

Enter your protection class in the space provided below.

Enter type of construction in the space provided below.

How many stories are there?

What is the total square footage of your vacant property?

What is the square footage of the foundation of your vacant property?

Renovation/New Construction Status

Indicate limits for improvements/repairs/renovations or new construction.  Limits for the existing structure must add up to 100% of the completed value for renovation.

Are there renovation cost limits?

Yes No

Existing Structure

Improvements

Property in transit

Property off-site

Are there new construction limits?

Yes No

Building

Property in Transit

Property off-site

Theft

Underwriting Information

Please describe the work to be done.

What date is construction planned to begin?

-- mm/dd/yy

What date do you project construction will end?

-- mm/dd/yy

Will any portion of the structure be occupied prior to completion of the project?

Yes No

If yes, please describe occupancy rate.

0-25% 25-50% 50-75% 75-100%

Please describe how property is protected from theft, vandalism, illegal entry, illegal activity.

Select neighborhood classification.

Residential Rural Industrial Suburban Business District Other (Please explain in 'comment' box)

Has the property been occupied by vagrants in the past?

Yes No

Description of Work

Does the job involve any of the following?

Demolition of the structure:

Yes No

Excavation:

Yes No

Structural alterations:

Yes No

Unique or experimental design:

Yes No

Renovation after Fire/Vandalism:

Yes No

Modular units/manufactured homes:

Yes No

Mobile homes:

Yes No

Removal of lead, asbestos, or other pollutant:

Yes No

Please explain all yes answers:

Does the structure have a sprinkler system?

Yes No

If yes, please select all that apply:

On
Off
Indoor
Outdoor
Other (Please explain in 'comment' box)

Are there situations present that may cause/involve potential disputes at the worksite? (i.e. strikes, etc.)

Please indicate your ownership/management status

Owner
General Contractor
General Manager
Architect
Broker
Project Manager
Other (Please explain in 'comment' box)

Please tell us the name of your General Contractor:

Please tell us how much you paid for the structure:

Please describe your experience in real estate investing:

Do you sub-contract work to others?

Yes No

If yes, enter type of work in the space provided below.

If yes, please enter the labor cost for the work, due/paid to sub-contractor for here:

Are all sub-contractors required to carry insurance?

Yes No

Are certificates of insurance required from sub-contractors with insurance?

Yes No

Any history of bankruptcy?

Yes No

If yes, please describe type of bankruptcy:

Chapter 7
Chapter 13
Chapter 11
Other type of restructure (Please explain below)

If yes, please explain here:

Are there any mortgage payments (building or contents) overdue by 3 months or more?

Yes No

If yes, please explain:

Are there any tax liens against the property?

Yes No

If yes, please explain:

Has anyone with financial interest in the property been convicted of/indicated for any crimes related to loss of property owned now or during the past 5 years?

Yes No

If yes, please explain:

Is there any other insurance in force or to be secured on this property?

Yes No

If yes, please provide the following information: (Policy, Status, Date, Amount, Carrier) in the box below.

Comments: