KMRD Client Contact Information:

First Name *

Last Name *

Telephone *

Email *

KMRD Client Company Name *

Date * +

Project Description:

Upload Documents / Contract / Scope of Work Here if Applicable:

Project Name: *

Start Date: * 🛈 +

End Date: * 🛈 +

General Contractor: *

General Contractor's Address:

Same as KMRD Client?

Company Name: 🛈

Street Address:

Mailing City

State:

Zip:

County:

Township:

Location Name or Number:

Description of Work: *

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Will the Work Impact Load Bearing Walls?

If subcontractors are used will there be hold harmless and waiver agreements?

If existing building, is it sprinklered?

If Yes, will it remain operational?

Job Site Contact:

Site Contact Phone #:

Job Location Address:

City:

State:

Zip:

County:

Township:

Number of Buildings:

Distance Between Buildings:

Age of Building:

Intended Occupancy:

Total Square Footage:

Wall Construction:

Floor Construction:

# of Floors:

Roof Construction:

Foundation Construction:

Value and Insurance Limits:

Completion Value($):

Desired Limit($):

Transit Limit($):

Temporary Storage Loc. Limit($):

Soft Costs Annual Value($):

Loss of Rents Annual Value($):

Business Income Occurrence Limit($):

EQ Limit($):

Flood Limit($):

Performance/Hot Testing Limit($):

Other General Information:

Off Site Storage of Materials:

If Yes, How Much and Where:

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Types of Materials:

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Construction Techniques:

If Other Specify:

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Distance to Fire Department:

Type of Fire Department:

Paid

Volunteer

Fire Hydrants:

Number within 100ft:

Number within 500ft:

Project Includes Fire Hydrant Installation:

Water is on at Nearest Fire Hydrant:

Distance to Nearest Fire Hydrant(in feet):

Private Fire Protection:

Sprinkler System/Standpipes:

Description of Premises Protection Security (Fencing, Guards, Etc.):

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Adjacent Exposures/Buildings Structures:

If Yes, Describe:

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Mud Slide Exposure?: *

Run-Off Exposure?: *

Subsidence Exposure?: *

Mud Slide Exposure?: *

Flood Exposure?: *

Blasting Required?: *

Have there been any losses?: *

If Yes to Any of the Above, Please Describe:

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If yes, please complete the Loss Addendum (attached at end of questionnaire) for each loss over the past 3 years.

Additional Named Insured Requirements

Insured Name:

Street Address:

City:

State:

Zip:

Mortgagee (if required)

Insured Name:

Street Address:

City:

State:

Zip:

Renovations Project Supplemental Questions & Risk Considerations

Is this a renovation project?: *

What is the contract value to renovate the property($)?

Why is the building being renovated?

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What is the age of the structure in years?:

If Change of Occupancy, Repair Fire Damage, or other, please explain:

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Is the building vacant?

If yes, explain:

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What is the physical condition of the structure (excellent, poor, etc)?:

If poor, then explain:

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Is the building structurally sound?:

If no, explain:

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Had building been renovated previously?

If yes, provide date:

What is the nature and extent of the work performed?:

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Describe connection to existing structure if any:

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Are there any structural modifications?

Has the building been gutted?

If yes, explain:

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Is there an operational sprinkler system?

Is there an operational standpipe system?

Will the sprinkler system operational while work is in progress?:

Is there a burglar alarm?:

Will burglar alarm system operational while work is in progress?:

Is the structure currently occupied?:

How is it occupied?

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Will the building be occupied while work is in progress?:

If yes, describe how construction will work around existing occupancy:

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Will there be any sweating of pipes, welding, cutting or other flame operations?:

Will it be supervised?:

If yes, explain:

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Are fire extinguishers on hand at all times?:

If no, explain:

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Is a fire watch provided once hot work operations have ceased?:

If no, explain:

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Do you require coverage for the existing structure on the builders risk policy?:

If yes, please complete the following questions:

Is coverage for the existing structure required by the insurance specifications?

If yes, explain:

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Is the building currently insured?:

If yes, by whom? If no, explain:

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Add any additional comments:

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Thank you for utilizing this system. You should receive confirmation of your request via email. A KMRD representative will reach out to you with questions if we have them. If you do not hear from us, feel free to call at 866-957-KMRD (5673) or contactus@kmrdpartners.com.

This form is for communication purposes only. This form does not bind coverage.