I. Insured information Insured name Mailing address City Province Postal code Insured’s form of business: Corporation Individual Joint venture LLC Partnership Other: Description of named insured: Owner/Contractor Owner Contractor II. Builder information Does builder/remodeller/owner/GC have at least 2 years experience? Yes No If “No”, the risk is not eligible Is the builder’s name different than the insured? Yes No If “Yes”, would you like to add the builder as an other named insured? Yes No Additional Interests (* 1. Additional Insured – Builder, 2. Additional Insured – Other, 3. Loss Payee, 4. Mortgagee, 5. Premium Finance Company): # Name Address City Province Postal Code Phone Type * Details of last 5 projects, completed in last year 2 years Other: Project Name Description (include construction type, stories, occupancy) Value Has the builder/remodeller had any single loss over $10,000 in the last 3 years (include insured/uninsured losses)? (BuildersRisk claims only) Yes No If “Yes”, include the date, description, and amount of each loss below (attach separate sheet if required): Date (MM/DD/YYYY) Description Amount (including reserves) III. Policy information Type of project New Construction Remodelling/Renovation excluding coverage for the existing structure Remodelling/Renovation including coverage for the existing structure If “Remodelling/Renovation” project, must fill out Additional Section X on page 4 Policy period 1 year from effective date 6 months from effective date (Remodelling only) 9 months from effective date (Remodelling only) Type of property Residential (1-4 Single Family Units) Commercial Policy effective date (MM/DD/YYYY) Personal information is processed by April and its affiliates and service providers, both domestic and foreign. Contact the April Privacy Officer for information on foreign service providers at For the purpose of the Insurance Companies Act (Canada), this document was issued in the course of the Company’s insurance business in Canada.
V. Project information Has the project started? Yes No If “Yes”, date started: (MM/DD/YYYY) Percent complete: % Will renovations begin within 60 days of the policy effective date? Yes No Is there a sales contract on this structure? Yes No Estimated length of project (in months): New Construction project only: Is the structure modular? Yes No If “Yes”, must fill out Additional Section IX on page 4 Remodelling project only: Scope of work Remodel Remodel/Minor Structural Restructuring Description of work to be performed: Restructuring project only: Have architectural plans been developed for this project? Yes No Has a licensed engineer reviewed & approved the plans? Yes No Please provide the name of the engineer or engineering firm that approved the project: VI. Coverage information Base Coverages Coverage description Limit Deductible New Constr. Total completed value of any one structure Greater than $4,000,000 will require underwriter approval $ Total completed value of all covered property Greater than $4,000,000 will require underwriter approval $ $ Remodelling Amount of renovation/improvements [1] Greater than $4,000,000 will require underwriter approval $ Existing building(s) or structure(s) amount (if existing structure is insured) [2] Actual Cash Value but not more than Market Value $ Total completed value of all covered property [1] + [2] Greater than $4,000,000 will require underwriter approval $ $ Additional Coverages Coverage description Default limit * Increased limit (New Construction only) Back-up or overflow of sewer, drains or sumps $5,000 Debris removal $20,000 Fire department service charge $10,000 Pollution clean up and removal $15,000 Reward $10,000 Scaffolding, construction forms and temporary structures $20,000 Scaffolding re-erection $10,000 Property at a temporary storage location $10,000 / 2.5% Property in transit $25,000 / 5% Valuable papers and records $20,000 *Cannot increase default limits for remodellers
VI. Optional Additional Coverages Coverage description Limit Deductible Better green endorsement Building rating: Certified Silver Gold Platinum $ Same as structure Business income and extra expense ** New Constr. Commercial only $ Check how many days: 3 5 7 10 14 21 30 Change order endorsement Include the change order endorsement If “Yes”, what is the percentage? 10% 20% 30% Same as structure Earthquake What is the building shape? Rectangle/box L shaped T shaped U shaped Other If “Other”, specify: $ $100,000 / 10% Flood Flood coverage Yes No Is the risk located in a known flood zone? Yes No Basement Yes No Will the HVAC or other systems and equipment be on the first floor or in a basement? Yes No Does this project consist of multiple buildings? Yes No If Yes, how many? If in zone: $50,000 / 10% If not in flood zone: $25,000 / 5% Testing coverage for building systems ** New Constr. only Add testing coverage for building systems and coverage Yes No Same as structure Waiver of coinsurance ** New Constr. Commercial only Add waiver of coinsurance Yes No Extended permission to occupy endorsement ** New Constr. Commercial only Add extended permission to occupy endorsement Yes No If yes, what is the percentage requested until expiration date of the policy? % Soft ** New Constr. only Soft costs include: Advertising & promotion expense Interests on Construction Loan Architect, Engineer & Consultant Fees Real estate & Property Tax Assessments Commissions or fees for renegotiation of leases Insurance Premiums Legal and Accounting Fees Fees for Licenses & Permits $ Check how many days: 3 5 7 10 14 21 30 ADDITIONAL SECTIONS (complete only if prompted to from a previous section or if coverage is required) VI. Protection class information (complete if structure is unprotected) Number of miles to the nearest fire station: Is the fire department manned 24 hours a day? Yes No