REI New Build Request

Life is Risky. RiskWell.

Please complete the form below and we will contact you ASAP when your request is completed.

**NOTE THAT THIS REQUEST WILL BE PROCESSED FOR THE EFFECTIVE DATE REQUESTED. IF A BACKDATED CANCELLATION IS NEEDED, SUPPORTING DOCUMENTATION MUST BE PROVIDED.**

"*" indicates required fields

1Contact Info

2Property Info

3Wrap up

Are you a current client of RiskWell?*

What effective date do you want for your new insurance?*

Please note, we are not able to backdate coverage. Today's date is the first available day for coverage to begin.

How long is the project expected to take?*

Your Name*

Your Date Of Birth*

Is the project held in your personal name or another legal entity (LLC, etc...)*

Entity Name*

Phone Number*

Email*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address*

Street Address Address Line 2 City State ZIP Code

County

Building Type*

# Of Units*

Tell us the number of units that you own/need coverage for.

Are you the GC or the Developer*

How many years of experience do you or your GC have as a General Contractor?*

Building Coverage Amount Needed ($)*

For a "flip" property, use the purchase price + your renovation estimate to determine the property coverage amount.

Square footage of dwelling:*

Construction type?*

How many stories will the building be?*

Policy Payment Method*

Note that if you select "title company or escrow account" you will be required to enter lender/mortgagee information.

Lender/Mortgagee*

Lender/Mortgagee Name*

Please provide the full name of the lender.

Lender/Mortgagee Email*

Input the primary contact email for the lender/mortgagee

Lender/Mortgagee Mailing Address*

Street Address Address Line 2 City State ZIP Code

Full name and contact info of GC that will be assisting on this project*