ROYAL OAK UNDERWRITERS, INC.

8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com

ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers

BUILDERS RISK PROGRAM APPLICATION APPLICANT NAME: Mailing Address: City:

State:

Zip:

Telephone: Policy Dates: Location of Property: Property New Construction:

Renovation:

Current Value $

Addition:

Value of Renovation/Addition $

Property Limit Requested: Building $ Perils Requested: Fire:

(100% Coins unless indicated) E.C.:

Vandalism:

Other:

Deductible $ Liability General Liability Limits: Occurence:

$ _______________

Personal/Advertising:

$ _______________

General Agregate:

$ _______________

Medical Payments:

$ _______________

Products:

$ _______________

Fire Legal:

$ _______________

General Information Year Built: No. of Stories:

Year Renovated:

Year Systems Upgraded:

Construction Type:

Year Roof Replaced:

Intended Disposition of Property (i.e., sell, rent, occupy): Describe neighborhood - i.e., rural, commercial, residential: Loss History:

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Royal Oak Underwriters, Inc.

ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers

Bankruptcy Status:

8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com

Mortgagee:

Previous Carrier: Other pertinent information:

Producer Name:

Applicant Signature:

Address:

Date:

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Royal Oak Underwriters, Inc.