One-Time Report

THIS REPORT MUST BE RECEIVED WITHIN 30 DAYS OF
LAST BUSINESS DAY OF EACH MONTH.
Policy Number: 
Producer: 

Insured’s Name and Address:

Report Month/Year:

Make checks payable and remit to:
HUB International Mid-America
6100 S. Yale Ave., Ste. 1900
Tulsa, OK 74136

Agent #35-271 | 1-800-375-8631

Coverage is for 12 months but can be extended an additional 12 months if you submit a Re-Report.
FOR PURPOSES OF THIS REPORT, THE BUILDING PROCESS STARTS WHEN COVERED
PROPERTY IS FIRST PLACED AT THE CONSTRUCTION PROJECT

Job Site Location Completed Value
(Numbers only)		 Rate Re-Report Premium
Street Address/City Zip Code
TOTAL

NEW CONSTRUCTION RATES PER $100.00 OF VALUE

Dwelling – Protection Class
2-8 Inside City 9-10 Outside City
.385 .56

Note: The above rates are for wood frame and brick veneer over wood frame.
For other construction types, contact your agent for rates.


RENOVATION RATES PER $100.00 OF VALUE

Protection Class
Excluding Existing Structure Including Existing Structure
2-8 Inside City 9-10 Outside City 2-8 Inside City 2-8 Outside City
.47 .62 .70 .92

The undersigned insured, by the above policy number, does hereby certify that the following represents a true and accurate listing of all “construction projects” and the “completed value” of such “construction projects” for the specified month.

A REPORT WITH ACTIVITY MUST BE SUBMITTED EACH MONTH!

Authorized Representative Today's Date

Must be signed by Insured or Authorized Representative


Please sign below

Use mouse, stylus, or finger to draw signature.

Rev. 04.15