Legal Name of Proposed Policyholder
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Coverage Start Date
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MM
DD
YYYY
Mailing Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Address where Equipment is stored the majority of the time (if different)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Does this location have an alarm system connected to an outside monitoring company?
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Contact Person
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First Name
Last Name
Phone
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(###)
###
####
Email
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Website Address
Please describe your business operations:
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Current Insurance Company
Current Policy Expiration
MM
DD
YYYY
Current Premium
Have you ever had an equipment claim in the last 5 years?
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If yes, please explain (Claim Date, Payout and Loss Details)
Do you travel with your equipment outside of the United States?
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(Note: coverage does not include travel outside of the United States)
Do you travel with your equipment to Mexico?
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Does any of your equipment go underwater?
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If yes, is it in a waterproof or protective case?
Is any single item(s) valued at $150K or more?
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Owned Production Equipment (Description)
Replacement Value (including Sales Tax)
Owned Sports, Leisure & Recreational Equipment (Description)
Replacement Value (including Sales Tax)
Owned Musical Instruments & Sound Equipment (Description)
Replacement Value (including Sales Tax)
Business Personal Property (Description)
Replacement Value (including Sales Tax)
Rented Equipment From Others (Description)
Replacement Value (maximum value at any one time)
For equipment you own, is any single item valued at $5,001 or more (replacement cost including sales tax)?
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If yes, please complete the below and include all items $5,001 or more. (INCLUDE: Make, Model, Serial Number and Replacement Cost of Each)
Do you have any items that are custom made?
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If yes, do you have any custom made equipment valued over $5000 a piece?
If yes, please complete the details of the item(s) below. (Description of Item, Date Made, Materials Used and Their Costs, Labor Costs)
Please list: Make, Model, VIN#, Year Built and Replacement Value
Do you have any equipment that is permanently attached to the trailer?
If yes, what is the total value of equipment that is permanently attached to the trailer?
Is any single item of the permanently attached equipment over $5,000 a piece?
If yes, please provide scheduled equipment info (make, model, serial number, and replacement cost)
Where do you store your trailer when not in use? (Please select one)
What kind of security does this location have to prevent the public from entering? (Please check all that apply)
Does your trailer have an alarm system?
Does your trailer have a lock?
If yes, please describe
Do you ever leave the trailer out overnight at a job or event?
If yes, will your Equipment be attended/guarded at ALL times (24/7)? (Please select one)
Where is it parked when left overnight at a job or event? (Please select one)
Do you rent any of your owned equipment to the sole custody of others (unaccompanied by you or your employees) ?
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If yes, what is the maximum replacement value of owned equipment that you rent out to others at any one time (unaccompanied by you or your employees)?
Would you like to add coverage for Voluntary Parting and False Pretense?
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(this covers your equipment if the person/company renting or borrowing your equipment never returns it)
If yes, do you require your renters to sign a rental contract that makes them responsible for damages or theft to your equipment being rented?
Rental Reimbursement Coverage - only available with Owned Equipment Coverage (please select one)
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(If you have a covered claim, this coverage reimburses your rental fees for equipment rented to continue your business operations)
Continuing Rental Fees Coverage - only available with Rented Equipment from Others Coverage (please select one)
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(If you have a covered claim, this coverage reimburses your rental company for loss of rental income during your claim handling. This coverage has a 72
hour waiting period from the time the claim is reported in writing to the insurance agent or carrier)
Work Tools and Clothing - coverage options are per occurrence/per employee limits
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(this coverage is a separate limit for work related tools and clothing such as work uniforms)
Interior/Exterior Plate Glass Coverage
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Business Income and Extra Expense (Includes Rental Value) (Please note that home office locations are ineligible)
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(If you have a covered claim, this coverage reimburses you after the waiting period for loss of income and expenses to keep your business running such as
rent on another location. This coverage is location specific.)
If Yes, Limit Requested? (Maximum of $50,000)
Please schedule the location(s) for the requested Business Income Coverage (description, location address, city, state, zip):
*A business continuation plan must be received in order to bind this coverage.
*72 hour waiting period applies for Business Income and Extra Expense Coverage. In the states
of AL, CT, DE, FL, GA, LA MA, MD, ME, MS, NH, NJ, NY, NC, RI, SC, TX, and VA, the waiting period is increased to 120 hours
• I understand that this quote is for equipment coverage and does not apply to vehicles, liability insurance, or workers compensation coverage. · I understand that there is no coverage if I take my equipment outside of the United States. • I understand that my policy has no coverage for theft from an unlocked vehicle. • I have reviewed and understand the above statements. I certify that the information provided is true and accurate to the best of my knowledge. I understand that providing false information may affect my coverage and even void coverage in the event of a claim.
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