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EXHIBIT C

REPAIR COST QUESTIONNAIRE FOR BUILDERS

Instructions:

PLEASE PRINT CLEARLY IN INK. It is important that you answer every question and enter all the information requested in this questionnaire so that we can process your firm's claim. If an answer to a question is not known or the information requested is not readily available, do not leave the space blank as this will only delay the processing of the claim. If the answer to a question is not known, please indicate "UNKNOWN" in the blank space. If the information requested is not readily available, please provide a brief statement to that effect and indicate where or from whom such information can be obtained. If you need additional space, please use the back side of the last page or attach additional pages to the last page with a reference number indicating which question the information is intended to answer. All information submitted on any back page or additional pages shall be deemed to be incorporated by reference herein as if fully set forth on this questionnaire. You must swear in the presence of a notary public to the truth and completeness of all information your firm provides in support of its claim, as provided on the last page of this questionnaire.

Builder Name: _______________________________________________________________________________________________

Contact Person: _______________________________________ Phone Number: ________________________________

HOW Enrollment Number (see home owner certificate): _________________________________________

1) Describe Home: Foundation Types: Slab on Grade: ________ Basement: ________

Block: ____ Poured: ____ Pier & Beam: ____ Crawl Space: _____

Roof Framing: Truss: _____ Conventional: _____

Manufacturer: ____________________________________________

2) Engineer's and architect's name, address and phone number: _________________________________________________________

__________________________________________________________________________________________________________

Were there changes from the engineer or architect's design? Yes _______ No _______

If yes, please explain: _______________________________________________________________________________________

__________________________________________________________________________________________________________

3) Was the foundation engineered? _________ If yes, engineer's name, address and phone number:

__________________________________________________________________________________________________________

4) Were there any problems during construction? _____ If yes, explain: ________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

5) What was the developer's name, address, and phone number? ________________________________________________________

__________________________________________________________________________________________________________

6) Name, address, and phone number of subcontractors who worked on the structural components that are defective or damaged:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

 

REPORT TO HOME OWNERS - Page 19

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