BUILDERS RISK / WRAP-UP LIABILITY APPLICATION Please complete the General Information section for All Projects and specific sections for Wrap-Up Liability and Builders Risk for each coverage as required. GENERAL INFORMATION Broker Name: Broker Phone: Name of Insured: Insured Address: Name of Project: Address/Location of Project: Description of Project: Broker Fax: Project Participants (Names): Owner: Project Manager: General Contractor: Architectural/Engineering Consultant: Construction Period: From: to What is the bid date for this project? Project Data: Height of structure: Below Grade: # of Storeys # of Feet Above Grade: # of Storeys # of Feet Total Area (indicate sq. ft. or sq. meters): Construction Materials: Framework: Exterior Walls: Is an Exterior Insulation and Finish System (EIFS) used? Yes No If yes, does the EIFS assembly include expanded polystyrene insulation (EPS) or other combustible material? Yes No Roof: Structure: Covering: Floors: Structure: Covering: Adjacent Structures (attach site plan if available): Type of Construction Occupancy Distance North East South West Neighbourhood (describe): Security: Is site fenced? Yes No Height/Type: Watchman service? Yes No Hrs./Rounds: Alarm: Intrusion Fire & Smoke Alarm sounds to: Video surveillance? Yes No Type: Page 1 of 6
Subsurface Operations: Please describe the nature, duration, value and relationship to both the project and to adjacent structures. Blasting: Yes No Shoring: Yes No Piling Work: Yes No If yes, driven piles or drilled or augured piles Underpinning: Demolition? Yes No If yes, (a) anticipated value: (b) description of demolition operations: If any portion of the project will be occupied prior to completion, provide details (period, extent & nature of occupancy): Geotechnical Data and 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 modifications, please describe in detail: (c) If a copy of the geotechnical report summary and recommendations is not available, please describe soil conditions: (d) Type of foundation for each structure: (e) Are wood forms to be used? Yes No (f) Please describe any unusual or experimental features in construction or design: (g) Please describe any special features such as stained glass, glass curtain walls, artwork to be incorporated or included: Please list the Project Manager s/general Contractor s five largest projects in the past five years: Name Type Location Value Page 2 of 6
BUILDERS RISK (Complete only if this coverage is required.) Total Project Value: Hard Costs: $ (Labour, materials, professional fees to enter into and form part of the project.) Delayed Rental Income $ Soft Costs: $ Breakdown of Soft Costs $ Financial Costs $ Property Taxes, Insurance Premiums $ Additional Interest Expense $ Legal and Accounting Expenses $ Leasing & Marketing Expenses Equipment Breakdown Yes No Testing Limit ($250,000 included) Other Property Insured: (a) Existing building: $ (b) Temporary buildings, scaffolding, falsework, forms and hoardings: $ If coverage is required for either (a) or (b) above, please detail age, construction, condition and occupancy of such property: Please list the offsite locations and maximum value at each: Transit: Please list the key items (individual items over $100,000 value), point of origin, location where insured accepts responsibility Testing: Who will perform testing operations? Please describe the operations involved in testing and commissioning: Will the project involve the installation of any used equipment? Yes No Fire Protection: Distance to the nearest Fire Department: Name of City or Town providing protection: Hydrants (operational): Number within 1,000 ft.: Please describe private fire protection: Will the project be sprinklered? Yes No If yes, at which time will the sprinkler system be in operation? Flood Exposure: Nearest body of water: Name: Distance: Past flood history at site: Height of project above maximum flood stage: Page 3 of 6
Please describe the exposure during and after excavation from surface water and ground water: Please describe the precautions to be taken to prevent damage from flood: What is being done to prevent run-off damage? Site Risks: Please detail the exposures from: Winter heating conditions (type of heaters): Explosion (please detail the use of any highly flammable or explosive materials to be present on site): If Soft Costs/Delayed Rental Income Coverage is required, please detail: Contracted completion date: Anticipated completion date: Anticipated replacement times for key items if reorder necessitated (i.e. boilers, turbines, generators, etc.) Item Delivery Period Supplier Location Please detail the loss prevention measures that will be implemented to protect insured property: Claims Experience: Please detail any Builders Risk or Installation Floater claims incurred by any of the following during the past three years: Owner, General Contractor, Project Manager. Please indicate the date, amount and nature of claim. Page 4 of 6
WRAP-UP LIABILITY (Complete only if this coverage is required.) Total Project Value: $ Breakdown by Trade: Trade Amount Completed Operations Period: 12 months 24 months Other Limit of Liability $ Deductible $ Does the project attach to or communicate with an existing structure? Yes No Manner in which structures will connect or communicate: Occupancy of existing structure during construction: What operation and income is likely to be affected if the existing structure is damaged? Please detail exposures to utilities, including relocation thereof (both below and above grade): Please describe any offsite operations or locations which require insurance. Please detail the loss prevention measures that will 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.) Page 5 of 6
CONSENT in accordance with the Act Respecting the Protection of Personal Information If it should be necessary for the purpose of my file, I, undersigned, the applicant specifically consent that my broker and my insurers, for the time required to fulfill their functions: (A) Gather all the pertinent necessary information from the holders of my prior insurance files, intermediaries in the insurance industry, insurance companies, financial institutions, credit agencies, government records establishing driving experience, prevention, detection, or repression of crime agencies and institutions that gather and compile data on insurance risks and losses. for the purpose of establishing the premium and the assessment of risk; and, (if you would like to consent now) for the purpose of verification, assessment and the settlement of losses; Furthermore, I authorize my broker to sign on my behalf any request or form that may be necessary in order to gather information concerning me. (B) Disclose, in the case of my broker, the information obtained to insurers with whom he is doing business; when it is my insurers, to institutions that gather and compile data on insurance risks and losses and prevention, detection or repression crime agencies. Solely the employees, mandatories or representatives of my broker, insurers or of institutions referred to in this paragraph will have access to this information when required within the execution of their functions. Furthermore, I consent that holders of information concerning me and covered by the present consent be released from their confidentiality undertaking and that they convey the required information to my broker, my insurers, their employees, trainees or representatives. I acknowledge having been informed of my right to access to information obtained by virtue of the present consent and to have it corrected, if need be. Furthermore, I acknowledge having been informed that I may address all questions regarding the present consent to my broker and/or my insurers, their employees, trainees or representatives. This insurance application is considered to include all provisions for all forms to be issued in accordance with this contract. The total estimated policy premium is subject to adjustment. Signature of Applicant: Signature of Co-Applicant: Date: Page 6 of 6