Form Ap-15 - Supplemental Application - Builders' Risk Coverage

Form Ap-15 - Supplemental Application - Builders' Risk Coverage - North Carolina

SUPPLEMENTAL APPLICATION - BUILDERS' RISK COVERAGE

In order to expedite processing your Application, all applicable

items should be completed and this must be signed.

DATE: ______/______/______

TO:

NORTH CAROLINA JOINT UNDERWRITING ASSOCIATION

NORTH CAROLINA INSURANCE UNDERWRITING ASSOCIATION

Post Office Box 8009

NCJUA/NCIUA No.:

Cary, NC 27512

Name of Applicant:

Will the applicant (individual) be the owner-occupant of this dwelling when construction

has been completed?

_______

Yes

_______

Please advise builders' risk coverage (forms) desired:

Completed Dwelling Form DP-000 _____

DP-0002 _____

Endorsement DP-1143 (only if answer 1.a is Yes ______

Commercial Form CP-1199 ______

Other commercial Form (specify)

Date of commencement of construction: ______/______/______

A policy on a building under construction, using Commercial Form CP-1199, may be backdated

to the date construction commenced, if construction in progress is not more than sixty (60) days

and if the following statement is signed by the applicant:

No losses have occurred to this property since construction began that would

be covered under the policy provisions.

______/______/_____

Signature of Applicant

Date

Property for which insurance is desired:

Dwelling to be occupied: No. of Families ______ Owner ______ Tenant ______

Other - To be occupied as

New Building

other.

Additions or alterations to completed building.

If building rated - Fire Class Rate CSP Code _______

or Microfiche Risk I.D. No. _______

Location of Property on which insurance is desired:

Construction: _____ Frame _____ Masonry _____ NC or AAA - Height, # Stories _____

_____ Approved Roof _____ Unapproved Roof _____ Anticipated Area

Rating Classification:

a. Protection Class _____

b. _____ Inside City

c. _____ Outside City

If c. - within required distance of public hydrant and Fire Department.

NOTE: Must be signed

Signature of Applicant (Authorized Representative

for both Plans

accepted for Beach Plan)

THIS SECTION TO BE COMPLETED FOR NCIUA - BEACH PLAN ONLY

Certificate of building code compliance -- If the certificate required in Item 7 of the basic

Application has not been submitted, attach certificate (BP-20) (11-82) stating that the

structure is being built in substantial accordance with the NC Uniform Residential Building

Code or the NC Building Code, including the design-wind requirements therein. (Unless

Association has received blanket certificate from municipality.)

AP-15 (rev. 06/93)

Form Ap-15 - Supplemental Application - Builders' Risk Coverage - North Carolina

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