Homebuilder's Insurance Application

1. General Information

Legal Name(s) of Your Business(es):
Contact Name:
Mailing Address:
City:	State:
Zip:
Street Address:
(if different from mailing address)
Business Phone: (      )	Home Phone: (      )
Fax: (      )	E-mail:
Why are you requesting a quote? Are you unhappy with your current Agent for any reason other than price?

2. Construction Information

Explain you experience in the construction business including number of years and positions held:

For the next 12 months, Please answer the following:

New Home Starts

1. Total number of projected new home starts:______________ 2. Average completed value of start excluding lot cost:$_______________ 3. Of the total number above, how many are spec. homes?:______________ Remodeling Jobs 1. Total number of projected remodeling jobs:_____________ 2. Average completed value of job: $_____________________ Commercial Jobs 1. Total number of projected commercial jobs:______________ 2. Average completed value of job: $_____________________ 3. Description of types of commercial jobs:        Have you ever used EIFS or Synthetic Stucco on jobs in the past? If so, explain techniques used and total number of jobs:       Do you currently use HBW 2-10 Warranty on your homes? ____YES ____NO If so, on what percent?:_________% 3. Workers Compensation Do you presently carry a Workers Compensation policy?: _______YES _______NO If yes, answer the questions below: 1. Name of current insurance company (NOT Agency): _______________________________________________ 2. Name of current insurance agency: _______________________________________________ 3. Are the corporate officers, partners, or sole proprietor included or excluded from coverage?: ______Included _______Excluded 4. Are you current on all premium payments?: ________YES ______NO Complete the claim information below: Year # of Claims Dollars Paid and Reserved Current     $  Prior     $  1st Prior     $  2nd Prior     $  ____________Check here if none 4. General Liability Do you presently carry a General Liability Policy: _______YES _______NO If yes, answer the questions below: 1. Name of current insurance company (NOT Agent): _______________________________________________ 2. Name of current insurance agency: _______________________________________________ 3. Are you current on all your premium payments: ______YES _______NO 4. What are your General Liability limits? Complete the claim information below: Year # of Claims Dollars Paid and Reserved Current     $  Prior     $  1st Prior     $  2nd Prior     $  ____________Check here if none 5. Workers Compensation and General Liability Premium Information Projected amounts to be paid over next 12 months to your employees (W-2):

Employee Name	Is Employee an Officer,Partner,or Sole Proprietor?	Payroll Amount
	__YES /__ NO
Type of Work Performed by Classification (ex: Clerical, Exec.Supervisor,Real Estate Sales etc.)

Employee Name	Is Employee an Officer,Partner,or Sole Proprietor?	Payroll Amount
	__YES /__ NO
Type of Work Performed by Classification (ex: Clerical, Exec.Supervisor,Real Estate Sales etc.)

Employee Name	Is Employee an Officer,Partner,or Sole Proprietor?	Payroll Amount
	__YES /__ NO
Type of Work Performed by Classification (ex: Clerical, Exec.Supervisor,Real Estate Sales etc.)

Employee Name	Is Employee an Officer,Partner,or Sole Proprietor?	Payroll Amount
	__YES /__ NO
Type of Work Performed by Classification (ex: Clerical, Exec.Supervisor,Real Estate Sales etc.)

Employee Name	Is Employee an Officer,Partner,or Sole Proprietor?	Payroll Amount
	__YES /__ NO
Type of Work Performed by Classification (ex: Clerical, Exec.Supervisor,Real Estate Sales etc.)

Employee Name	Is Employee an Officer,Partner,or Sole Proprietor?	Payroll Amount
	__YES /__ NO
Type of Work Performed by Classification (ex: Clerical, Exec.Supervisor,Real Estate Sales etc.)

Projected amounts to be paid over the next 12 months to your uninsured sub-contractors (1099):

Type	Workers Compensation (WC) Certificate on File	General Liability (GL) Certificate on File	If no Certificate on file, for either WC or GL, List Amounts to be Paid
Framing	___YES/___NO	___YES/___NO	$_________
Interior Trim	___YES/___NO	___YES/___NO	$_________
Roofing	___YES/___NO	___YES/___NO	$_________
Land Clearing	___YES/___NO	___YES/___NO	$_________
Concrete	___YES/___NO	___YES/___NO	$_________
Driveways/Sidewalks
Wall board	___YES/___NO	___YES/___NO	$_________
Plumbing	___YES/___NO	___YES/___NO	$_________
Electrical	___YES/___NO	___YES/___NO	$_________
HVAC	___YES/___NO	___YES/___NO	$_________
Painting	___YES/___NO	___YES/___NO	$_________
Hardwood Floor	___YES/___NO	___YES/___NO	$_________
Tile	___YES/___NO	___YES/___NO	$_________
______________	___YES/___NO	___YES/___NO	$_________
______________	___YES/___NO	___YES/___NO	$_________
______________	___YES/___NO	___YES/___NO	$_________
______________	___YES/___NO	___YES/___NO	$_________
______________	___YES/___NO	___YES/___NO	$_________
______________	___YES/___NO	___YES/___NO	$_________

How many acres of vacant land do you own?_______________________________________
How many acres of land that has been subdivided for development do you own?:_________________________

6. Builders Risk (Temporary Property Insurance on the Housing Start to Protect Against Fire,Windstorm, Theft, Vandalism, ect.)
Do you currently carry Builders Risk Insurance on your housing starts? _____YES _____NO
If yes, please answer the questions below:
1. Name of current insurance company (NOT Agency):
_______________________________________________
2. Name of current insurance agency:
_______________________________________________
3. Current rate that you are paying per $100 of completed value:___________________________________________

Complete the claim information below:

Year	# of Claims	Dollars Paid and Reserved
Current Prior 1st Prior 2nd Prior	__________ __________ __________ __________	$_________________ $_________________ $_________________ $_________________
_____ Check here if none

From the day the materials are delivered to the jobsite, How many months on average is it before the start is sold?:_________months

7. Business Auto
1. Name of current company (NOT Agency):
______________________________________________
2. Name of current insurance agency:
_______________________________________________

Schedule of Vehicles:

Year	Make	Model	Original Cost When New	Current Liability Limit	Current Comprehensive Deductible	Current Collision Deductible
_______ _______ _______ _______	__________ __________ __________ __________	__________ __________ __________ __________	$__________ $__________ $__________ $__________	$________ $________ $________ $_______	$________ $________ $________ $________	$________ $________ $________ $________

Schedule of Drivers:

Full Legal Name	Date of Birth	State of Drivers License Issue	Drivers License #
	___/___/___
	___/___/___
	___/___/___
	___/___/___
	___/___/___

Claim Information:

Year	# of Claims	Dollars Paid and Reserved
Current Prior 1st Prior 2nd Prior	__________ __________ __________ __________	$_________________ $_________________ $_________________ $_________________
_____ Check here if none

8. Equipment to be Insured

Year	Make	Model	Description	Actual Cash Value
				$
				$
				$
				$
				$
				$
				$
				$
				$

Claim Information:

Year	# of Claims	Dollars Paid and Reserved
Current
Prior
1st Prior
2nd Prior
______Check here if none

9. Miscellaneous Information:

©2000 Sadler & Company, Inc.