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| INSURED INFO |
| * Business/Name | |
| * Your Full Name | |
| * Email | |
| * Send me a copy by: | Fax # |
|
| RISK INFO |
| * Insured's Interest | |
| * Construction Begin Date | |
| Bid Date | |
| * Duration of Project | |
| * Policy Period | - |
|
| LIMITS OF INSURANCE |
| * Construction Project $ | |
| * Transit $ | |
| * Temp. Storage $ | |
| * Any One Loss $ | |
| * Deductible | $ |
|
OPTIONAL COVERAGES |
Earthquake
| Extra Expense (Soft Costs)
|
Flood
| Loss Of Business Income
|
Loss Of Rents
|
|
CONSTRUCTION PROJECT |
| * Type | |
* Location: | | |
| |
PROJECT DESCRIPTION |
| * Intended Occupancy | |
| *# Floors | |
| *Square Footage | |
| *# of Buildings | |
* Type of Installation (Include Materials/ Equipment to be Installed) | | |
| |
PROTECTION INFO |
| * Public Protection Class | |
| * Distance to Fire Hydrant | |
| * Distance to Fire Dept. | |
| * Type of Fire Dept. | |
| * Materials Stored On Site? | Where? |
Fenced
| Well Light Property
|
Watchmen
|
Fire Extinguishers on Site
| Cutting/Welding Supervised
|
Smoking Permitted
| Unsupported Walls Braced
|
Trash Removal Provided
| Trash Burning On Site
|
|
| HOLDER INFO |
| * Name | |
| * Attention | |
| * Address | |
| * City | |
| * State | |
| * Zip Code | |
| Add to Policy As: | |
Additional Notes: | | |
| |
| * Send to Holder by: | |
| Fax # or Email Address | (If left blank, certificate will be mailed.) |
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