Strategic Insurance Services, LLC - Builders Risk Form

Please complete the following information.
Company Name *
Contact Person *
Company Address
Address *
City *
State/Province *
ZIP/Postal Code *
Country *
Phone *
Email *
example@example.com
Coverage Start Date *

Month Day Year
Address of Property to be Covered
Address *
City *
State/Province *
ZIP/Postal Code *
Country *
Construction Cost *
excluding land
Number of Stories *
New Construction or Remodel? *

New Construction Remodel
Do you want to cover the existing structure?

Yes No
What is the value of the existing structure?
In at least 10 words, please describe your project
Do you need:

Mortgagee/Loss Payee Additional Insured
Additional Structures
Description of any additional structures
including detached garage
Construction Cost of Each Structure
Number of Stories
Square Footage
Should be Empty: