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| DATE______________________ Underwriter________________________________________________ Agency______________________________________________________________________________ Contact Name_____________________Phone#_____________________Fax#____________________ NAMED INSURED_____________________________________________________________________ Address____________________________________________________________Zip_______________ CONTRACTOR________________________________________________________________________ Address____________________________________________________________Zip_______________ Years in Business_____ FL Contractor Lic.#________________Gen. Liab. Carrier#_________________ Prior Builder's Risk carriers______________________________________________________________ 3 years Loss History on builder's risk______________________________________________________ PROJECT NAME / DESCRIPTION / INTENDED OCCUPANCY ____________________________________________________________________________________ ____________________________________________________________________________________ PROJECT ADDRESS ___________________________________________________________________ ___________________________________________Zip____________County____________________ Cross Streets (to locate on map)_________________________________________________________ ESTIMATED COMPLETED VALUE (100%) New Construction $___________________ Renovations(if any)$__________________________ Existing Structure(if any)$_____________EXCLUDED by policy but may be considered by endorsement Addition (if any)$____________________ Soft Cost (optional; i.e. loss of rents)$____________ Transit Limit $_______________________Temporary Storage Limit $______________________ CONSTRUCTION DATA (check applicable) WALLS Frame [ ] Concrete Block [ ] Steel [ ] Masonry w/Steel [ ] Reinforced Concrete [ ] ROOF Wood Joist [ ] Steel Joist [ ] Metal Deck [ ] Built Up [ ] Concrete [ ] Other [ ] UNDERWRITING DATA: Square Footage__________________ Number of Stories__________ Number of Buildings___________ Renovation/ Addition - yes [ ] no [ ] If yes: Year Built ____________ Demolition - yes[ ] no[ ] If yes, description ______________________________________________ Feet to Fire Hydrant_______ Miles to Fire Station_______ Name of and Distance to Closest Body of Tidal Water________________________________________ Protection Class__________ EC (wind) Zone________________ Flood Zone______________________ Security at Jobsite: Fenced [ ] Lighted [ ] Watchmen [ ] hours___________ Locked trailer [ ] Gated Community [ ] Other (if any) [ ]__________________ Special Form Deductible: $___________________ Optional Deductible: $________________________ Wind & Hail Deductible: $____________________ Windstorm & Hail Excluded** yes [ ] no [ ] **Windstorm required to be excluded if FWUA eligible. Can only exclude windstorm if FWUA eligible. EVIDENCE of WINDSTORM POLICY WILL BE REQUIRED!! Has Construction Started?_______ If so, what date did construction start?______________ Percentage of completion now?______ Estimated Start Date ________________ Number of Days to Complete_________________ |
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Halcyon Underwriters, Inc. :: 2600 Lake Lucien Dr. Suite 304 Maitland, FL 32751-7234 Phone - 407-660-1881 or 1-800-393-9090 :: Fax - 407-660-0525 or 407-660-1882 |