Builder's Risk Discovery Form Step 1 of 6 16% Contact Person's Name(Required) First Last Cell Phone Number(Required)Email Address(Required) Business Legal Name Organization Type(Required)Individual / Sole ProprietorLimited Liability Corp (LLC)Limited Liability Partnership (LLP)Incorporated (Corp)OtherNumber of Owners(Required)1 Owner2 Owners / Partners3+ Owners / PartnersBusiness Website Address Mailing Address(Required) Street Address City State ZIP / Postal Code What does your current RE portfolio consist of?(Required) This is my only RE property (other than primary residence) I have 5 or less RE properties I have more than 5 RE properties What coverage is your business interested in?(Required) Builder's Risk Premises Liability Check all that apply Risk ExposurePlease provide the following detailed information regarding the property for which you are seeking coverage.Property Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date Property Purchased(Required) MM slash DD slash YYYY Approx date work will begin:(Required) MM slash DD slash YYYY Who will be doing the work?(Required) Owner/Insured General Contractor How many years of industry experience(Required) Intended occupancy after work is completed:(Required) Rental For Sale Unknown Purchase price(Required)Estimated Construction Cost (Labor & Materials Included)(Required)Current Sq ft:(Required)For New Builds, enter the estimated finished sq ft Will you be adding sq ft to the existing structure?(Required) Yes No Current Number of Stories(Required)For New Builds enter the number of stories/levels that will be built.Will you be adding additional stories/levels to the existing structure?(Required) Yes No Year ELECTRIAL was last updated:(Required)For new builds, enter the current year. Type of ELECTRICAL:(Required)Copper with Circuit BreakersFuse BoxKnob and TubeAluminum wiringYear PLUMBING was last updated:(Required)For new builds, enter the current year. Type of PLUMBING:(Required)CopperPEX/PVCGalvanized PipeIronClay/ConcreteYear HVAC was last updated:(Required)For new builds, enter the current year. Type of HVAC:(Required)Central w/Gas HeatingCentral w/Electrical HeatingWindow UnitsMini-splitsNoneYear ROOFING was last updated:(Required)For new builds, enter the current year. Type of ROOFING:(Required)Comp ShinglesMetalRolled RoofingClay/TileWood ShinglesBuilt-up Tar & GravelTPOOtherHow long will it take to complete the work?(Required)Please consider that materials and labor are still taking longer than normal in your estimate.3 months or less3 - 6 months6 - 9 months9 - 12 monthsIs the existing structure going to be insured on any other insurance policy?(Required) No - Include existing structure on this policy No - I do not wish to insure the existing structure Yes N/A - this is a new build Will there be any structural work done on the property?(Required)For new builds, check "Yes" Yes No Please advise what structural work will be completed:(Required) New Build Adding Sq Ft to existing structure Roof Pitch change Foundation Removing/moving interior load bearing walls Other (please specify other work on the next page) Engineers Report(Required) Do you agree to email us a copy of the engineers report showing the structural integrity to include the engineer's name. Contractor name:(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code PhoneHow many years of experience does the contractor have?(Required) Please provide a detailed explanation of the work you will be doing to the property below.(Required) How did you first hear about us?(Required) Current Customer Family/Friend Referral Channel Partner Referral (Mortgage Broker, Realtor, Other Insurance agent) Google Search Social Media Post (Facebook, Instagram, Twitter) Local Event Other File uploadYou can upload any engineers report, scope of work or insurance requirements to help us determine the best insurance program to put in front of you. Drop files here or Select files Max. file size: 5 MB, Max. files: 5. Consent(Required) Do you agree & consent to the following:All the information submitted on the application is true and correct to the best of my knowledge. By submitting this request you are authorizing My Insurance Group, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit, and loss history) to confirm the data submitted. Submitting your quote request does not constitute a binding confirmation of a new or revised insurance coverage. My Insurance Group is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, text and email as needed. You may opt-out of all future communication at any time by making your preferences known to us.CAPTCHA