X/TwitterThis field is for validation purposes and should be left unchanged.Applicant InformationApplicant Entity Type:(Required) Individual Partnership Corporation LLC Joint Venture Other Applicant Name:(Required)Applicant's Name:(Required) First Last Applicant's Company Name:(Required)(N/A if you don't have one)Owner's Name:(Required) First Last Business Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the business address the same as the mailing address?(Required) Yes No Mailing Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:(Required)Fax:Email:(Required) Website FEIN (Tax ID #):(Required)Does the applicant have a DBA (Doing Business As) name:(Required)In what year did the applicant start operations?(Required)Please describe the applicant's day-to-day business operations:(Required)Main area of practice, type of services provided, products, etc. - Please be detailedAre there any locations or business interests that are owned by the applicant but not shown on the application?(Required) Yes No If so, please list:(Required)Are there high-valued goods, including merchandise at your location?(Required) Yes No If yes, what is the approximate value of your inventory?(Required)What is the value of your business personal property? (BPP are all your furniture, computers, printers, etc. Basically, anything you will take with you if you move)(Required)Annual Gross Revenue:(Required)Contractor License:(Required)State(s) / Area of Operation:(Required)Licensed for Business in State(s):(Required)Equipment Coverage InformationType of Equipment to be Insured: (Check all that apply)(Required) Heavy Construction Equipment (e.g., bulldozers, excavators, cranes) Contractor’s Tools & Machinery Agricultural Equipment Medical or Diagnostic Equipment Photography or Film Equipment Mobile Equipment (e.g., food trucks, generators) IT & Electronic Equipment (e.g. servers, laptops, etc.) Other (please specify): Other (please specify):(Required)What is the total estimated value of the equipment to be insured?(Required)Do you own or lease the equipment?(Required) Own Lease Is there a loss payee for any of the equipment?(Required)Hint: This would apply if equipment was purchased with a loan that has yet to be paid off. Yes No Loss Payee Info:(Required)Please list all loss payeesLender NameAddressPhone #Equipment Add RemoveIs the equipment new or used?(Required) New Used Does the applicant transport equipment between job sites?(Required) Yes No Do you have GPS tracking or anti-theft devices on your equipment?(Required) Yes No Is the equipment stored at a secured location when not in use?(Required) Yes No If yes, please describe storage conditions (e.g., fenced yard, locked warehouse, surveillance cameras):(Required)Do you have an existing maintenance program for your equipment?(Required) Yes No Do employees take equipment off-site?(Required) Yes No Equipment SchedulePlease list all equipment to be covered under this policy.Equipment(Required)Name/DescriptionYearMake/ModelSerial NumberValue ($)Owned/Leased Add RemoveCoverage & Claims InformationRequested Coverage Limit:(Required) $50,000 $100,000 $250,000 Other: Please specify other:(Required)Requested Deductible Amount:(Required) $500 $1,000 $2,500 Other: Other:(Required)Do you currently have equipment floater insurance?(Required) Yes No If yes, name of current insurer:(Required)Policy expiration date:(Required) MM slash DD slash YYYY Current coverage limit:(Required)Claims & Loss HistoryHave you had any equipment-related claims in the past five years?(Required) Yes No If yes, provide details including date, amount paid, and type of claim:(Required)Have you had any stolen, damaged, or lost equipment incidents?(Required) Yes No If yes, provide details:(Required)Has any insurer canceled, denied, or declined to renew coverage in the past five years?(Required) Yes No If yes, please provide details:(Required)Additional Coverage OptionsWould you like to include coverage for the following? (Check all that apply) Rental Equipment Coverage Employee-Owned Tools & Equipment Coverage Business Interruption Due to Equipment Breakdown Flood or Earthquake Damage Coverage Transit Coverage (for equipment being transported) Additional Comments or Special Considerations(Please provide any other relevant information that may impact your insurance coverage needs.) Δ
