COURSE OF CONSTRUCTION INSURANCE

☐ WRAP-UP LIABILITY☐ BUILDERS RISK

Applicant’s Instructions:

Please complete the GENERAL INFORMATION section for ALL PROJECTS and specific sections for WRAP-UP LIABILITY and BUILDERS RISK according to requirements.

Special Note:

Each construction project presents unique exposures. Detailed informations and submission off all documents / plans requested increases our efficiency and results in the most favourable terms. When available, please provide:

A – BREAKDOWN OF VALUES for the various structures and types of work;

B – SITE PLAN indicating distance, construction and occupancy of exposures;

C –SCHEDULE OF CONSTRUCTION;

D – SUMMARY and RECOMMANDATIONS from the GEOTECHNICAL REPORT;

E – SCHEDULE indicating BUILD-UP OF CONTRUCTION VALUES.

  1. GENERAL INFORMATIONProposed Effective Date: YY/MM/DD
  1. Give the full name of applicant and subsidiary companies.

Type here /
  1. Principal Address:

Type here /
  1. Description of Project:

Type here /
  1. Address / Location of Project:

Type here /
  1. Project Participants (Names):

Owner: / Type here /
Project /
Construction Manager: / Type here /
General Contractor: / Type here /
Prime Architectural /
Engineering Consultant: / Type here /
Geotechnical Engineer / Type here /
  1. Construction Period:

From: / Type here / To: / Type here /
  1. Project Data:

Height of structure: / Storeys / Feet or Metres
Below Grade: / Type here / Type here /
Above Grade: / Type here / Type here /
Total Area: / Type here / Type here /
  1. Construction Materials:

Framework: / Type here /
Exterior Walls: / Type here /

Is an Exterior Insulation and Finish System (EIFS) used?☐ YES☐ NO

If yes, does the EIFS assembly include expanded polystyrene insulation (EPS) or other combustible

material?☐ YES☐ NO

Roof:Structure: / Type here / Covering: / Type here /
Floors: Structure: / Type here / Covering: / Type here /
  1. Adjacent Structures (Attach site plan if available):

Type of Construction / Occupancy / Distance
North / Type here / Type here / Type here /
East / Type here / Type here / Type here /
South / Type here / Type here / Type here /
West / Type here / Type here / Type here /
  1. Neighbourhood (Describe):

Type here /
  1. Security:

Is site fenced? ☐ YES☐ NOHeight / Type:Type here

Watchman service?☐ YES☐ NOHrs. / Rounds: Type here

Alarm:☐ Intrusion☐ Fire / SmokeAlarm sounds to:Type here

Video surveillance?☐ YES☐ NO Type :Type here

  1. Subsurface Operations:

Please describe the nature, duration, value and relationship to both the project and to adjacent structures.

Blasting:Type here

Shoring:Type here

Piling Work:Type here☐ Driven Piles or☐ Drilled or Augured Piles

Underpinning:Type here

  1. Are there any demolition operations?☐ YES☐ NO

If yes, please provide a description of demolition operations: Type here

  1. If any portion of the project will be occupied prior to completion, please provide details:

Type here /
  1. Geotechnical Data and Construction Data:

a)Has a geotechnical report been completed?

☐ YES☐ NO

If Not, please advise reasons: Type here

b)Will the project be constructed in compliance with geotechnical recommendations?

☐ YES☐ NO☐ With modifications

c)If a copy of the geotechnical report summary and recommendations is not available, please describe soil

conditions: Type here

d)Type of foundation for each structure: Type here

e)Are wood forms to be used ? ☐ YES☐ NO

  1. WRAP-UP LIABILITY (Complete if this coverage is required.)
  1. Total Estimated Project Value:Type here(Attach breakdown if available.)
  1. Competed Operations Period: ☐ 12 months☐ 24 months☐ Other Type here

Limits of Liability / Deductible Options
$Type here / $Type here
$Type here / $Type here
$Type here / $Type here
  1. a)Does the project attach to or communicate with an existing structure? ☐ YES☐ NO

b)Occupancy of existing structure during construction: Type here

c)What operation and income is likely to be affected if the existing structure is damaged? Type here

  1. Please detail exposures to utilities, including relocation thereof:

Type here
  1. Please provide details of the LOSS CONTROL PROGRAM to be implemented to protect others from operations (i.e., traffic control, preconstruction surveys, vibration monitoring, preconstruction location of utilities and notification to others of interruption thereof, etc.) :

Type here
  1. BUILDERS RISK (Complete only if this coverage is required.)
  1. Total Estimated Project Value:$Type here (Attach breakdown if available.)

Hard Costs: $Type here (Labour, materials, professional fees to enter into and form part of the project.)

Soft Costs: $ Type here(Financial costs, additional interest expenses, miscellaneous carrying costs.)

$ Type here Financial Costs

$ Type here Additional Interest Expenses

$ Type here Leasing and Marketing Expenses

$ Type here Legal and Accounting Expenses

$ Type here Miscellaneous Carrying Costs

Note: Architectural and engineering fees are not Soft Costs but Hard Costs for the purpose of this coverage

  1. Other Property to be insured:

a)Existing Building: $Type here

b)Temporary buildings, scaffolding,

falsework, forms and hoardings: $Type here

c)Job site field offices (excluding contents): $Type here

  1. Is BUSINESS INTERRUPTION COVERAGE (DELAYED START-UP) required?☐ YES☐ NO

If yes, please detail the type of income: Type here for $Type here

Total limit being $ Type here per month for Type here month(s) indemnity period.

Coverage / Limits / Deductibles
Value of Project / $Type here / $Type here
Other Property to be Insured / $Type here / $Type here
Sublimits / Limits / Deductibles
Soft Costs (other than 3 above) / $Type here / $Type here
Delayed Start-Up (see 3 above) / $Type here / Type heredays
Offsite / $Type here / $Type here
Transit / $Type here / $Type here
Testing (electrical / mechanical breakdown during commissioning) / Type here weeks / $Type here
  1. Is TESTING COVER required? ☐ YES☐ NO
  1. Fire Protection:

a) Distance to the nearest Fire Department: Type here

b) Name of City or Town providing protection: Type here

c) Hydrants (operational): Number within 1,000 ft:Type here

d) Please describe private fire protection:Type here

e) Will the project be sprinklered?☐ YES☐ NO

If yes, at which time will the sprinkler system be in operation? Type here

  1. Flood Exposure:

Nearest body of water:Name: Type hereDistance: Type here

  1. Site Risks:

Please detail the exposures from winter heating conditions (type of heaters): Type here

3CLAIMS Experience:

Please detail any Builders Risk or Installation Floater claims (Exceeding $10,000 per loss) incurred by any of the following during the past three years: Owner, General Contractor, Project / Construction Manager. Please indicate the date, amount and nature of claim.

Type here

4DECLARATION AND SIGNATURE:

By signing this application, the undersigned is attesting to the accuracy of the information provided. If any information provided by the applicant in this application is found to be false or misleading and would alter the Insurer’s decision to provide the insurance coverage applied for, it is agreed between the Insurer and the applicant that the coverage, if under binder or policy, is subject to immediate cancellation.

The undersigned acknowledges that any personal information contained in this application has been collected in accordance with all applicable privacy legislation.

The undersigned confirms that it has obtained the necessary consents to the collection, use, and disclosure of such information for the purposes of assessing the application for insurance, investigating and settling claims, detecting and preventing fraud, and acting as required or authorized by law.

Signature of ApplicantDate

Title

Name of Broker