147 Installation_Builders Risk Section

Applicant name*
Proposed effective date*
Propoosed expiration date*
Select billing plan
Payment plan
Premium advertising
Type of risk
-----OPEN REPORTING FORM------------------------------------------------
Coverage:
Limit at any single location ($)
Limit per disaster ($)
Limit at a temporary location ($)
Transit limit ($)
Causes of Loss and Deductible:
If cause of loss was earthquake, state sub limit($)
If cause of loss was earthquake, state deductible($)
If cause of loss was flood, state sub limit($)
If cause of loss was flood, state deductible($)
If cause of loss was special, state deductible($)
If cause of loss was broad, state deductible($)
If cause of loss was basic, state deductible($)
Territory:
Receipts:
Gross installation receipts in the past 12 months ($)
Estimate gross installation receipts in the next 12 months ($)
Jobs/Values:
Residential job type
Annual number
Duration
Maximum number of jobs in progress
Average number of jobs in progress
Maxmimum cost or value of jobs in progress ($)
Minimum cost or value of jobs in progress ($)
Average cost or value of jobs in progress ($)
Material cost (percent of total)
Commercial job type
Annual number
Duration
Maximum number of jobs in progress
Average number of jobs in progress
Maxmimum cost or value of jobs in progress ($)
Minimum cost or value of jobs in progress ($)
Average cost or value of jobs in progress ($)
Material cost (percent of total)
Additional Interests:
Interest 1
Name of interest
Address
City
State
Zip
Description of interest
Is certification required?
Interest 2
Name of interest
Address
City
State
Zip
Description of interest
Is certification required?
Interest 3
Name of interest
Address
City
State
Zip
Description of interest
Is certification required?
Interest 4
Name of interest
Address
City
State
Zip
Description of interest
Is certification required?
Rigging:
Describe all hoisting or other operations requiring rigging
Transportation/Security:
Describe job site security
-----SPECIFIC JOB------------------------------------------------------------
Coverage:
Limit at location ($)
Limit at temporary location ($)
Transit limit ($)
Causes of Loss and Deductible:
If cause of loss was earthquake, state sub limit($)
If cause of loss was earthquake, state deductible($)
If cause of loss was flood, state sub limit($)
If cause of loss was flood, state deductible($)
If cause of loss was special, state deductible($)
If cause of loss was broad, state deductible($)
If cause of loss was basic, state deductible($)
Job Term/Values:
Job term commencement
Job term completion
Contract amount ($)
Value of owner supplied property ($)
Security:
Describe job site security
Job Description:
Describe the work to be performed
Additional Interests:
Interest 1
Name of interest
Address
City
State
Zip
Description of interest
Is certification required?
Interest 2
Name of interest
Address
City
State
Zip
Name of interest
Description of interest
Is certification required?
Interest 3
Name of interest
Address
City
State
Zip
Name of interest
Description of interest
Is certification required?
Interest 4
Name of interest
Address
City
State
Zip
Description of interest
Is certification required?
Transportation:
Amount shipped ($)
Percent for applicants vehicles
Percent by common/contract carrier
Distance involved
Rigging:
Describe all hoisting or operations requiring rigging