Mikkelsen Insurance Services
Information needed for Builders Risk Policy quote. California Only! (Our Privacy Statement)
Name:
Business Name:
Address:
City: CA Zip code:
Phone:
E-mail address:
Current G/L Carrier:
Expiration date:
C.L. Number: Type? Years in bus? Total yrs. exp.?
Form of Business: (Indiv. )(Corp. )(Partnership )(JV. )
Business description:
Number of structures built or remodeled in the past 12 mos.

Property Information

Address of property being insured:
City:
County & Zip Code:
Type of structure:
Description of project:
Completed Value: - Deductible:
Is coverage needed for existing structure?: Yes No
Value of existing structure:
Distance to nearest fire hydrant:
Distance to nearest fire station:
Is fire district volunteer or paid?
Best time to contact you for any additional information needed:

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