PBIA Digital Forms

ALL REQUIRED INTAKE INFORMATION MUST BE COMPLETED

Section 1 of 3

Applicant and Contractor Information

Provide the named applicant and contractor contact details.

Applicant Name

DBA

Phone Number

Name of Contractor

Contractor License #

Contractor Street Address

Contractor City

Contractor State

Years of Experience

Section 2 of 3

Project Information

Capture the project dates, address, construction type, and limits.

Proposed Effective Date

Length of Project

Estimated Completion Date

Project Street Address

City

State

Zip Code

Building Type

Project Type

Description of Project (Scope of Work)

Number of Stories

Anticipated Occupancy

Last Update: Roofing / Plumbing / Electrical

Leave blank for new construction.

Total Sq. Ft. of Completed Project

Construction Type

Is this a Mobile or Manufactured Home?

YesNo

Requested Limit

Has BR Losses in Last 3 Years

Section 3 of 3

Optional Coverages

Confirm any additional coverage selections before submission.

Temporary Storage

Property In Transit

Soft Costs

"Soft costs" are project expenses that are not direct labor or materials and can increase when completion is delayed.

Equipment Breakdown

Premises Liability

IncludedNot Included

California: Premises Liability not available for individuals, husband and wife/domestic partnerships. Limited Liability Companies, Corporations, and Contractors may be eligible.

All required fields are marked with *