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Please provide the following:

Producer's Name

Address

City

Province      Postal Code  



Additional Insured


Effective Date:

Applicants name

Address of project

City

Province       Postal Code  


Mailing Address

City

Province       Postal Code  







PERILS: Please check one or both boxes:

Cost of Project (100% replacement cost.)
Soft cost incl loss of income
(100% must be reported and cannot be purchased exclusively.)

Limit of Liability $
Limit of Liability $
Grand Total/max cost of project
 $

If you made a mistake or need to change numbers, clear the form before starting over
PERILS: Please check one of the following:

All risk Including Earthquake and Flood
All risk only,Excluding Earthquake and Flood

Buildings with multiple construction types must be classified as the highest rated construction class when the highest rated construction exceeds 25% of the project.

ANNUAL RATE: Please check one of the following:
Construction

All risk Excl. EQ & Flood All Risk Incl. EQ and Flood
Frame/BV**
1.20 1.25
Fire restrictive
0.14 0.18
Non-combustible
0.16 0.21
Masonry/Tilt-up
0.19 0.23
Deductible Info
Warranty Info
PROTECTION CLASS:
All Risk Excluding     1 - 3        4 - 6  = 1.30        7 - 10  = 1.50      
All Risk Including     1 - 3        4 - 6  = 1.30        7 - 10  = 1.50      

Risks which fall in the 4-6 class or the 7-10 class will be surcharged as noted above.
Risks which fall in the Brush Area will automatically warrant a 200 Foot Brush Clearance.
$ x =
x
=
Total cost of project(100%) Rate Protection


THE STATEMENTS ON THIS APPLICATION ARE MADE FOR THE PURPOSE OF OBTAINING INSURANCE. THIS APPLICATION WILL BECOME A PART OF THE POLICY, IF ONE IS ISSUED, AND IF ANY STATEMENT IS NOT TRUTHFUL, THE POLICY WILL BE NULL & VOID.


Sub Total: $

Total Gross Premium:
 		$