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March 5, 2021
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Insured Information
Contact Email Address *
How did you hear about us? *
Facebook
Post Card
Website
Referral
Brad Hancock
Scott Kirby
Emory Estes
Susan Elliott
June Landa
Karen Easter
Melissa Cano
Other
Insured Name *
Mailing Address
Mailing Address 2
City
State
Zip
Name of Primary Contact *
Phone Number *
Preferred Method of Contact
Phone
Email
Project Information
Project Address *
Project Address 2
City *
State *
Zip *
Please select your involvement in the project? *
General Contractor
Sub Contractor
Property Owner Acting as General Contractor
Property Owner with Separate General Contractor
Is the general contractor/builder currently insured and able to provide a certificate of liability insurance? *
Yes
No
N/A
?
Please provide the number of years general contractor or builder has in construction.
Name of Acting General Contractor or Builder *
?
Type of Builders Risk *
New Residential Construction
New Commercial Construction
Remodel Residential
Remodel Commercial
Completed Building Value *
If currently under construction please provide the % completed and current value of completed project at this time.
Estimated Start Date Of Project *
?
Estimated Date of Completion *
Construction Type *
Brick Veneer
Frame
Masonry
Metal
Other
Roof Type *
Composition
Metal
Slate
Tar & Gravel
Wood Shingle
Other
Number of Stories *
Square Footage *
Any Additional Interests? *
Yes
No
?
If yes to above - please provide name and address of each additional interest.
Please select all utilities currently connected on project: *
None
Electric
Water
Gas
?
Please provide a complete description of the project:
Choose the best description of the project to be completed: *
Click on the "?" for definition of each selection
New Ground Up Construction
Remodel
Remodel/Minor Structural
Restoration/Major Restructuring
New Addition With Some Remodel
Other
?
If the project is for a remodel - please answer the following two questions:
Value of Existing Building
Value of Rennovations
* = Required Field
Disclaimer Notice
- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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