Southwest Commercial Insurance Agency, LLC
Project Name:
*
Date insurance needed
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Types of Entity
*
Lot Address
*
City
*
State
*
Zip
*
Mailing address
Main Telephone
*
Main Mobile
Fax Number
Contact Person
*
Contact Person Phone Number
Contact Person Email
*
Years of Experience
# of projects in last 12 months
# of projects in next 12 months:
# of losses in last 3 years
Builder Name (if not named insured):
General Information
Named Insured
*
Website
Project Information
Project Type
*
Structure Type
Construction Type
Construction Type
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Superior Non-Combustible
Superior Masonry Non-Combustible
Poured Concrete
Concrete Tile-up
Asbestos & Stucco
Concrete Block
Steel
Earth Shelter
Frame
Adobe
Joisted Masonry
Log
Masonry
Metal/Aluminum Siding
Other
Pre-Fabricated
Fire Resistive/Superior
Metal/Plastic Siding
Trailer (Mobile Home)
Masonry Veneer
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Has the project started?
Yes
No
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If yes, how long ago?
Renovation/Remodel
Yes
No
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Improvement Contract amount
Actual Cash Value of Current Structure
Insure Current Structure?
Yes
No
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Year existing structure built
Additional square footage added?
Yes
No
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Occupancy of Structure during Remodel
Yes
No
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Are load bearing members of the existing structure being modified, removed or added
Yes
No
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If yes, explain in detail
Alarm
Yes
No
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Sprinklered
Yes
No
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Any previous loss caused by fire, flood or vandalism?
Yes
No
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New Construction
Yes
No
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Attached
Yes
No
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Detached
Yes
No
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Total New Construction Contract Amount
Deductible Options
$1,000
$2,500
$5,000
$10,000
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Project Location
Loc Address
Loc City
Loc State
Loc Zip
Loc County
Total Square Footage of Completed Project
Number of Stories
Estimated Completion Date:
Distance to Fire Hydrant
Distance to Fire Station
Loss Payee
Yes
No
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Mortgagee
Yes
No
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Additional Insured Information
Yes
No
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Institution Name:
Contact person
Contact Person Email
Address
City
State
Zip
Reference or Loan Number
Is there anything unique about this project or do you have any questions or comments?
Yes
No
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