Builders Risk Quotation from TC Irons Haines & Haines Insurance

Privacy Policy-We routinely collect personal and/or business information that is needed as part of the quoting and underwriting process. We also collect the same information as part of service and update activities. The Haines & Haines/T.C. Irons Agency will not share that information, or use it in any other way, with outside parties, vendors, etc.

Builders Risk Quotation

GENERAL INFORMATION

Name of Insured / Corporation:

DBA (if applicable):

Mailing Address:

City:

State: Zip:

Company Web site Address
Year Business Started
Any Claims / Losses	YES No
Ever Filed Bankruptcy or Reorganization?	YES No
Developer or General Contractor
Limits Required for Subcontractors
Has Coverage Been Declined, Cancelled or Nonrenewed in Last 3 Yrs?	YES No

PHYSICAL LOCATIONS (if more than 5 include in Notes Section on Bottom of Page)

Street Name City State Zip

LOC 1.

LOC 2.

LOC 3.

LOC 4.

LOC 5.

NEW CONSTRUCTION (if applicable) YES NO

# Homes Built
Last 12 Months Est. Homes
Next 12 Months # Spec Homes
Last 12 MOnths Est. Spec. Homes
Next 12 Months

Avg. Length of Construction
(in months) Completed Value per Dwelling
(Excl. lot) Max. Completed Value of Home
(Excl. lot) Avg. Sales Price per Dwelling Max. Sales Price per Dwelling

# of Homes Built Last Yr.

Est. # Homes Built In Next 12 Months

Do You Build in Multiple Subdivisions? YES No
Any Over 3 Stories in Height? YES No

Any Over 4 units? YES No

Do you Plan on Remodeling Homes? YES No

Construction Type

MODEL HOME (if applicable) YES NO

# of Models to Insure Avg. Model
Home Value Max. Model
Home Value Avg. Contents Value Max. Contents Value

Any Models Over 3 Stories? YES No

Do Models Have Active Security Alarms? YES No

Age of Models

Construction Type

MULTIFAMILY
(if applicable and over 4 units) YES NO

Completed Value

Number of Units

Construction Type

Number of Stories

Approx. Start Date / End Date

More Than 1 Building YES No

# of Buildings

If More Than 1 Building - Distance Between?

Prior Experience Building Multi-family YES No

FIRE SAFETY INFORMATION

Distance from Hydrant

Distance to Fire Department

Is Fire Dept. Volunteer or Paid? VOLUNTEER PAID

COVERAGE INFORMATION

Do You Want to Exclude Profit? YES No

Limit at Any One Dwelling

       Other Coverage Limit

Limit in Any One Loss

       Other Loss Limit

Deductible

       Other Deductible

CONTACT INFORMATION
First Name Last Name Email Phone Fax Questions / Comments / Notes
Send my quotation via	E-Mail Fax Regular Mail Call me by Phone!

All quotes are based on the information that the applicant provides, and are subject to change based on final underwriting by the individual carriers.

Our Mission Statement

Dating back from 1872 our mission is clear:

To serve our clients with the utmost respect, integrity and professionalism while providing a comprehensive risk management program at competitive pricing

Policy Coverage
and Disclaimer

Contact

	Haines & Haines/ T.C. Irons
16 West Front Street Florence, NJ 08518 Phone: 609.499.0237 Fax: 609.499.4077	230 High Street PO Box 158- Burlington, NJ 08016 Phone: 609.387.0606 Fax: 609.387.5337	1-3 Bank Street Suite E Medford, NJ 08055 Phone: 609-953-2282 Fax: 609.953.7719
	Wesley Insurance Service Agency 1194 Parkway Avenue Trenton, NJ 08628 Phone: 609.883.4190 Fax: 609.538.0274