Form C: Application for Construction Insurance

Transcription

1 Form C: Application for Construction Insurance Broker Information: Broker: BFL CANADA Insurance Services Inc. Contact: Address: 200, 1177 West Hastings Street, Vancouver, BC, V6E 2K3 Phone Number: Facsimile Number: Builders Risk/Course of Construction Wrap-Up Liability GENERAL INFORMATION 1. Name of Applicant: 2. Address of Applicant: 3. Name of Insured as it is to appear on the Policy (if different from 1. above): 4. Name of Project: 5. Address/Location of Project: 6. Description of Project: 7. Project Participants (Names): Owner: Project/Construction Manager: General Contractor: Prime Architectural/Engineering Consultant: Geotechnical Engineer: 8. Construction Period: From: To: Policy Term (if different from above): From: To: 9. Construction Values: Hard Costs: (attach breakdown if available) (Labour, materials, professional fees to enter into and form part of the project.) Soft Costs (if required): (attach breakdown if available) (Finance costs, additional interest, leasing and marketing expenses, legal and accounting expenses, other carrying costs.) 10. What is the bid date for this project? 11. By what date do you require a quote? Page 1 of 8

2 12. Construction Data: Height of structure: Below Grade: Storeys Above Grade: Total Area (indicate Sq. Feet or Sq. Metres): Construction Materials: Framework: Exterior Walls: Roof: Structure: Floors: Structure: Covering: Covering: Feet or Metres 13. Adjacent Structures (attach site plan if available): North East South West Type of Construction Occupancy Distance 14. Security: Is site fenced? Yes No Height/Type: Watchman service? Yes No Hrs./Rounds: Site lit during hours of darkness? Yes No Alarm: Intrusion Fire/Smoke Alarm Sounds to: 15. Will all or any part of the project be shut down for more than thirty (30) consecutive days? If so, please explain: 16. Neighbourhood (describe): 17. Subsurface Operations: Describe nature, duration, value and relationship to both the project and to adjacent structures. Blasting: Shoring: Pile Driving: Underpinning: 18. Is this a fast track project? Yes No If so, detail experience with similar projects: 19. List Project Manager s/general Contractor s five (5) largest projects in the past five (5) years: Name Type Location Value (100,000 s) 5. Page 2 of 8

3 BUILDERS RISK/COURSE OF CONSTRUCTION (Complete this section only if this coverage is required.) 1. Coverage Limits Deductibles Value of Project (if different from 9. in General Information) Other Property to be Insured Sub-limits: Soft Costs (if different from 9. in General Information) days waiting Delayed Start-up period Offsite In-transit Testing (electrical/mechanical breakdown during commissioning) weeks 2. Delayed Start-up/Business Interruption coverage: (a) Is Delayed Start-up coverage required? Yes No If yes, please advise: Contracted completion date: Anticipated replacement times for key items if reorder necessitated (i.e. boilers, turbines, generators etc.): Item Delivery Period Supplier Location (b) Is Business Interruption coverage required? Yes No If yes, detail type of income: for Total limit being per month for month(s) indemnity period 3. List Offsite locations and maximum value at each: Transit: List key items (individual items over 100,000 value) point of origin, location where insured accepts responsibility (F.O.B.): 5. Testing: (a) Who will perform testing operations? (b) Describe operations involved in testing and commissioning: (c) Will project involve installation of any used equipment? Yes No 6. Other Property to be insured: If coverage is required to existing structure, equipment to be furnished by the owner, etc., detail age, construction, condition, occupancy of such property. Page 3 of 8

4 7. Location Information: (a) Distance to nearest Fire Department: (b) Name of City or Town providing protection: (c) Hydrants (operational): Number within 1,000 ft.: (d) Describe private fire protection: (e) Will the project be sprinklered? Yes No If so, at which time will the sprinkler system be in operation? 8. Construction Data: (a) Has a geotechnical report been completed? Yes No If not, please advise reasons: (b) Will the project be constructed in compliance with geotechnical recommendations? Yes No With modifications If with modifications, describe in detail: (c) If copy of geotechnical report summary and recommendations is not available, describe soil conditions: (d) Type of foundation for each structure: (e) Are wood forms to be used? Yes No (f) Describe any unusual or experimental features in construction or design: (g) Describe any special features such as stained glass, glass curtain walls, artwork to be incorporated or included: 9. Flood Exposure: (a) Nearest body of water: Name: Distance: (b) Past flood history at site: (c) Height of project above maximum flood stage: (d) Describe exposure during and after excavation from surface water: (e) Describe precautions to be taken to prevent damage from flood: (f) What is being done to prevent run-off damage? 10. Site Risks: Detail exposures from: (a) Winter heating conditions (type of heaters): (b) Explosion (detail use of any highly flammable or explosive materials to be present on site): 11. Provide details of LOSS CONTROL PROGRAM to be implemented to protect insured property: 12. Claims Experience: Detail any Builders Risk or Installation Floater claims (exceeding 10,000 per loss) incurred by any of the following during the past three (3) years: (Owner, General Contractor, Project/Construction Manager); (Indicate date, amount, nature of claim): 13. Loss Payee/Mortgagee: Page 4 of 8

5 14. Sub-Contractors Questionnaire Do you check the previous loss experience and history of all sub-contractors? Yes No Do you have your own panel/list of approved sub-contractors? Yes No Do you require all sub-contractors to bid/tender and award jobs on price alone? Yes No Do you insist on written contracts with all sub-contractors Yes No Do you insist all sub-contractors carry full in-force General Liability Insurance? Yes No What percentage of the sub-contractors for the proposed project will NOT have worked for you before or in the last 12 months? Page 5 of 8

6 WRAP-UP LIABILITY (Complete this section only if this coverage is required.) 1. Limits of Liability Deductible Options,000,000,000,000,000, Completed Operations Period: 12 months 24 months Other 3. Existing Structure(s): (a) Does the project attach to or communicate with an existing structure? Yes No Manner in which structures will connect or communicate: (b) Occupancy of existing structure during construction: (c) Business Interruption/loss of use for damages to existing structure: Yes No (d) Is coverage required for damage to existing structure? Yes No 4. Occupancy: If any portion of the project will be occupied prior to completion, provide details (period, extent and nature of occupancy): 5. Surrounding Exposures: Detail the exposures to the property (other than the project) resulting from demolition, blasting, pile driving, shoring, underpinning: 6. Utilities: Detail exposures to utilities, including relocation thereof (both below and above grade): 7. Describe any offsite operations or locations which require insurance. 8. Provide details of LOSS CONTROL PROGRAM to be implemented to protect others from operations (i.e. traffic control, preconstruction surveys, vibration monitoring, preconstruction location of utilities and notification to others of interruption thereof, etc.): 9. Claims Experience: Detail any liability claims (exceeding 10,000 per accident) incurred by any of the following which resulted from construction operations in the past three (3) years: Owner, General Contractor Project/Construction Manager. Indicate date, amount and nature of claim. 10. Additional Insured(s): Page 6 of 8

7 DUTY TO DISCLOSE In addition to providing all basic information necessary to enable us to place your risk, you must ensure that you comply with your duty to disclose, before inception of your insurance contract, all matters which a prudent underwriter would view as probably tending to increase the risk in relation to your insurance contract. If such matters are not disclosed, underwriters have the right to void the contract from its commencement which will lead to claims not being met. Similarly, any future changes must also be advised to us so that they may be provided to underwriters. Notes: All Limits, Sub-Limits, Deductibles, Adjustment Rates and Premiums are expressed in Canadian (CAD) Currency. All coverage will incept and expire at 12:01 AM standard time at the mailing address of the Applicant Completion of this application does afford or guarantee coverage. Coverage commences once policy is placed and confirmed in writing by underwriters. APPLICANT S CONSENT TO THE TRANSMISSION OF THE INFORMATION CONTAINED IN THE APPLICATION FORM I/we hereby acknowledge that the information collected in the Application form is acquired by BFL CANADA Insurance Services Inc., to be transmitted to one or more insurers for the sole purpose of obtaining an insurance policy, and will be kept confidential. Furthermore, I/we authorize insurers or service providers to: conduct verification, using outside sources, of the information contained in the Application form, in attached documentation and in subsequently provided documentation; in the event of a claim, transmit the submitted and verified information to loss adjusters, lawyers or other similar offices for the purposes of investigating, defending, negotiating or settling any claims, as required. SUPPLEMENTARY INFORMATION Each construction project presents unique exposures. Detailed information and submission of all documents/plans requested increases the efficiency and results in the most favourable terms. When available, please provide: Attached: (a) Breakdown of Values for the various structures and types of work; Yes No (b) Site Plan indicating distance, construction and occupancy of exposures; Yes No (c) Schedule of Construction; Yes No (d) Geotechnical Report; Yes No (e) Insurance Section from the Contract Specifications/Supplementary Conditions Yes No DECLARATIONS AND SIGNATURE It is understood and agreed that the completion of this Application does not bind the insurers to sell, nor does it obligate the Applicant to purchase the insurance. Page 7 of 8

8 Signature of Applicant Date Page 8 of 8