Applicant’s Name:

First Last

Mailing Address:

Street Address City State / Province / Region ZIP / Postal Code

E-mail:

Phone No.:

PROPOSED EFFECTIVE DATE:

From To

Applicant is:

Individual

Corporation

Partnership

Joint Venture

Limited Liability Company

Other

Limits Of Liability & Deductible Requested:

General Aggregate (other than Products/Completed Operations)

$

Products & Completed Operations Aggregate

$

Personal & Advertising Injury (any one person or organization)

$

Each Occurrence

$

Damage To Premises Rented To You (any one premise)

$

Medical Expense (any one person)

$

Other Coverage, Restrictions, and/or Endorsements:

$

Deductible

$

Exposure to other buildings/structures and estimated percentage of total projects during the next twelve (12) months:

Free standing buildings/structures (no abutting walls or shared common/party walls or foundations):

%

Buildings/structures with abutting walls or shared common/party walls or foundations:

%

Are shared walls or foundations shored up, as needed, before demolition begins?

Yes

No

Are the conditions of nearby structures documented before demolition begins?

Yes

No

Are procedures in place to verify address of demolition site prior to commencing work?

Yes

No

Does applicant have a formal loss control or safety program?

Yes

No

Indicate by method of demolition the estimated percentage of work to be performed during the next twelve (12) months:

Manual work by hand or handheld tools excluding jackhammers

%

Handheld jackhammers

%

Mechanical equipment (excluding cranes) such as, extended excavators, bull dozers, etc.

%

Cranes or other equipment with wrecking ball or similar apparatus

%

Cranes without wrecking ball (used for lifting of debris or equipment only)

%

Explosives/blasting

%

Robotic hydro-demolition

%

High pressure water-jet lance

%

Non-explosive demolition agents, such as, expansive grout

%

Road milling machines

%

Other

%

Prior Policy

Prior Policy Date

_______ to ________

Carrier Name

Coverage Type: Liab/PHD/MTC

POLICY #

# of Units Insured

Any loses within the past 5 years?

If YES please upload on the related documents attaching box below.

Amount Paid

Upload Your Current Insurance Policy or Related Documents

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Limits Of Liability & Deductible Requested:

Exposure to other buildings/structures and estimated percentage of total projects during the next twelve (12) months:

Indicate by method of demolition the estimated percentage of work to be performed during the next twelve (12) months:

Debris disposal and/or salvage operations:

Utilities:

Are job sites secured:

Additional Insured Information:

Prior Policy

Recents Articles

The Importance of Life and Disability Insurance for Financial Security

Safeguard Your Business: Understanding Professional Liability Insurance

April Insurance Agency

Get A Quote

Helpful Links

For Clients

Demolition Contractor Insurance Quote

Limits Of Liability & Deductible Requested:

Exposure to other buildings/structures and estimated percentage of total projects during the next twelve (12) months:

Indicate by method of demolition the estimated percentage of work to be performed during the next twelve (12) months:

Debris disposal and/or salvage operations:

Utilities:

Are job sites secured:

Additional Insured Information:

Prior Policy

Recents Articles

The Importance of Life and Disability Insurance for Financial Security

Safeguard Your Business: Understanding Professional Liability Insurance

April Insurance Agency

Get A Quote

Helpful Links

For Clients