Builders Risk Questionnaire | Wilson Insurance

The completion of this Questionnaire does not bind the company, nor does it obligate the applicant to purchase this insurance.

General Information

Project Type:

Legal Name of Owner(s):

Legal Name of General Contractor:

Project Name:

Occupancy When Completed:

Mortgage Details:

Name of Architect/Engineer and/or Mechanical/Structural Consultants:

Project Site

Legal Address:

Nature of Ground:

Soil:

Has a geo-technical report been completed? :

If yes, attach copy of report summary and recommendations.

Public Fire Protection:

* Fire Protection Classification
Protected – means “project site” within 3 miles of a responding fire hall and within 500 feet of a working public fire hydrant.
Unprotected – means “project site” which do not conform to the above “Protected”

Total Insured Value

Estimated completed contract price: $

Other Property to be insured: $

If coverage is required to existing structure, equipment to be furnished by the owner, etc., detail age, construction, condition:

Sublimits

Transit: $

Offsite: $

Delayed Start Up

Type of Income:

Limit: $

Soft Costs

Soft Costs: $

If soft costs/delayed start-up coverage is required, please detail

Scheduled Completion Date:

Anticipated replacement times for key items:

Deductible

Deductible Desired:

Contract Period

Number of Months:

Effective Date:

Periods of Partial Occupancy:

Percentage of work subcontracted:

Coverage required for sub-contractors:

If yes, list subcontractor, stating number of years experience and five years loss history:

If no, are certificates of insurance obtained:

What is the minimum limit of liability requested: $

Testing

Describe, in detail, any testing that will be performed and by whom:

Project Details

Height of structure

Stories Below Grade:

Feet Below Grade: feet

Stories Above Grade:

Feet Above Grade: feet

Total area: square feet

Type of Foundation:

Construction Materials

Exterior Walls:

Framework:

Floors structure and covering:

Roof structure and surfacing:

Any unusual or experimental features in construction or design:

Subsurface Operations: Describe nature, duration, value and relationship to both the project and to adjacent structures

Blasting:

Shoring:

Pile Driving:

Underpinning:

Dewatering (e.g. number of pumps):

Forms and form supports

Period of usage of wood forms/support:

Period of usage of steel forms/support:

Temporary Heating Type:

Type of Insulation:

Demolition Details:

Will the following be used:

	Will the following be used?
tarpaulins
plastic weather enclosures
straw
wood boarding
scaffolding
cranes

Asbestos, lead or urea formaldehyde foam abatement:

If yes, please describe:

Hazards/Exposure

Flood/surface water

Nearest body of water: Name:

Nearest body of water: Distance:

Past flood history at site:

Height of project above nearest body of water:

What is being done to prevent run-off damage:

Describe precautions, if any, taken to prevent Windstorm, Ice and/or Sleet damage to project:

Transit (Provide details of exposure – point of origin of key items):

Adjacent Structures (Type of Construction, occupancy and distance) :

Connecting/Surrounding exposures:

Special Precautions

Security:

If other, please describe:

Is entry to site possible only with an authorized person:

If no, explain :

Fire: (Describe private protection during construction):

Flood:

Explosion: (Detail use of any flammable liquids, gases or explosive materials to be present on site) :

Is there a “daily clean up” program? :

Is refuse burned on site?:

Scope of coverage desired

Form:

Flood coverage:

Deductible for flood coverage: $

Earthquake coverage:

Deductible for earthquake coverage: $

Testing of equipment:

Deductible for testing of equipment coverage: $

Delayed Start-up:

Deductible for delayed start-up coverage: $

Other coverage:

Deductible for other coverage: $

Loss History (Previous 5 Years)

Describe all Builders Risk losses sustained during the past five (5) years by the Owner/General Contractor.

Date of Occurence:

Description:

Amount of Loss: $

Date of Occurence:

Description:

Amount of Loss: $

Date of Occurence:

Description:

Amount of Loss: $

General Contractor's Experience

Number of years in business:

Bonded:

List similar projects in the past five (5) years:

Supporting Information

Supporting Business (Other policies including any liability or wrap-up coverage) #:

Please provide your account manager with the following:
Site Plan
Schedule of Construction
Schedule indicating Build-up of Construction values (construction budget sheet)
Structural plans & specifications

Prepared by:

Position(Indicate if Applicant: Owner, General Contractor, Engineer, Architect etc.):

Phone:

Facsimile:

E-mail:

Website: