Builders Risk Application

221 S Hamilton Rd. Columbus, Oh 43213 614 236 8691 Fax 614 961 3408

Please provide us with the following information below
for Builders Risk/Course of Construction Insurance

This policy does NOT provide ANY liability coverage.

Email:
Name:
DBA:
Address:
City:
State:
Zip:
Phone:	--
Fax:	-- * Not Required
Deductible Requested? $
Address of Building Coverage is Requested for including county?
Completed Value of Building? $
Square Footage of Building?
Number of Structures?
Within 1000 feet of Tidal Waters?	NoYes
Who is the Builder?
If 'Owner Builder/Individual' provide name and address of General Contractor
New Construction or Remodel?
Commerical or Residential Building?
Construction Type?
Has construction begun?	NoYes
If 'Yes' what percent of the work has been done?
Mortgagee information if any? (Name,Address,Fax)
Any Further Questions/Descriptions: