Builder'S Risk Insurance Binder Request Form (Page 3 of 3) in pdf

Builder’s Risk Information Form

and Binder

This Binder is a Temporary Insurance Contract

Subject to the Conditions Shown Below

DATE: (1)

No. (Binder_No)

INSURED AND ADDRESS:

(2)

CONTRACTOR:

OWNER AND ADDRESS:

COVERAGE ORDERED BY:

PROJECT TITLE:

(3)

DESCRIPTION INCL SQ. FT.,

LOCATION PROT. CLASS

AMOUNT OF INSURANCE (incl.

(4)

sales tax, where applicable):

TERM OF POLICY:

(5)

COVERAGE:

Builder’s Risk - Broad Form, including the following: subject to the policy conditions,

limitations and exclusions.

Earthmovement & Flood (6)

Waiver of Subrogation

Removal of Occupancy Exclusion

Transit - Sublimit_Transit

Property at any Temporary Location - Sublimit_Offsite_

Pro Rata Policy Term Extensions

Storage

Expediting/Extra Expense - Sublimit_Expediting

Resultant Damage from Faulty Workmanship

Terrorism Exclusion Applies

Resultant Damage from Faulty Design

Cold Testing of Building Systems

Ordinance/Laws Coverage

Hot Testing

DEDUCTIBLES:

(7)

LENDER:

(Lender Address)

CANCELLATION NOTICE:

(8)

COMMENT: CONTACT THE CONSTRUCTION SERVICES DEPARTMENT FOR ANY EXTENSIONS IN COVERAGE TERM AND, ALSO, NOTICE OF CHANGES IN

CONTRACT AMOUNT AS THEY OCCUR DURING THE TERM OF THE PROJECT, AS THE FAILURE TO DO SO MAY RESULT IN A COVERAGE DEFICIT.

COMPANY & BEST’S RATING:

(9)

POLICY NUMBER:

(Policy Number)

BINDER EFFECTIVE:

12:01 A.M (10)

BINDER EXPIRES:

12:01 A.M

RATE:

PREMIUM:

MINIMUM EARNED PREMIUM:

(

Subject to Adjustment at Policy Issuance and Audit based on Final Contract Price, upon project completion).

This insurance is subject to the terms, conditions, and limitations of the policy(ies) currently in use by the Company.

This Binder may be canceled by the insured by surrender of this Binder or by written notice to the Company stating when cancellation will be effective.

This Binder may be canceled by the Company by notice to the insured in accordance with the policy conditions. This Binder is cancelled when replaced

by a policy. If this Binder is not replaced by a policy, the Company is entitled to charge a premium for the Binder according to the rules and rates in use

by the Company.

PARKER, SMITH & FEEK, INC. (11)

BY: (12)

2233 112th Avenue NE | Bellevue, WA 98004 | 425.709.3600

4000 Old Seward Hwy., Suite 200 | Anchorage, AK 99503 | 907.562.2225