Contact Name *

First Name

Last Name

Phone *

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever had an equipment insurance claim in the last 5 years? *

Yes

No

Does this location have an alarm system connected to an outside monitoring company? *

Yes

No

Do you travel with your equipment outside the United States more than 5 times per year? *

NOTE: coverage does not include travel to countries with US Sanctions

Yes

No

Do you travel with your equipment to Mexico? *

Yes

No

Does any of your equipment go underwater? *

Yes

No

If yes, is it in a waterproof or protective case?

Yes

No

Is any single item(s) valued at $150,000 or more? *

Yes

No

Rental Pick Up Date

MM

DD

YYYY

Rental Return Date

MM

DD

YYYY

Continuing Rental Fees Coverage (Optional - please select one)

(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)

NONE

$2,500

$5,000

Locked Vehicle Warranty - The policy has a Locked Vehicle Warranty, which states there is NO coverage for equipment stolen from an UNLOCKED vehicle. Do you want to remove this warranty and thus add back coverage for equipment stolen from an unlocked vehicle for an additional 10% charge?

Yes

No

For Equipment you own, is any single item valued at $5,001 or more (replacement cost including sales tax)? *

Yes

No

Do you have any items that are custom made equipment? *

Yes

No

If yes, do you have any custom made equipment valued over $5,000, any one item?

Yes

No

Does the location have a sprinkler system (active system)?

Yes

No

Does the location have a fire and burglar alarm connected to a monitoring service?

Yes

No

Do you have any equipment that is permanently attached to the trailer?

Yes

No

Is any single item of the permanently attached equipment over $5,000 each?

Yes

No

Where do you store your trailer when not in use?

(PLEASE SELECT ONE)

Personal Residence - away from public view

Personal Residence - on driveway

Guarded Parking Lot/garage - not at personal residence location

Other

What type of security does this location have to prevent the public from entering?

(Please check all that apply)

Monitored alarm system (*connected to a police station or alarm company)

Unmonitored alarm system (alarm that only makes noise)

Locked Fence

Guarded security (monitored 24/7)

Does your trailer have an alarm system?

Yes

No

Does your trailer have a lock?

Yes

No

Do you ever leave the trailer out overnight at a job or event?

Yes

No

If yes, will your Equipment be attended/guarded at ALL times (24/7)?

(Please select one)

Yes

No

It will be attended/guarded a majority of the time

Where is it parked when left overnight at a job or event?

(Please select one)

On the event grounds

At the event parking area

Other

Do you rent any of your owned quipment to the sole custody of others (unaccompanied by you or your employees)? *

Yes

No

Would you like to add coverage for Voluntary Parting and False Pretense? *

(this covers your equipment if the person/company renting or borrowing your equipment never returns it)

Yes

No

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?

Yes

No

Rental Reimbursement Coverage - only available with Owned Equipment Coverage (Please select one) *

(If you have a covered claim, this coverage reimburses your rental fees for equipment rented to continue your business operations)

None

$5,000

$10,000

$25,000

Continuing Rental Fees Coverage - only available with Rented Equipment FROM OTHERS Coverage (please select one) *

(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)

None

$2,500

$5,000

$10,000

$25,000

Work Tools and Clothing - coverage options are per occurrence / per employee limits: *

(this coverage is a separate limit for work related tools and clothing such as work uniforms)

None

$1,000 / $250

$5,000 / $500

$10,000 / $1,000

Interior / Exterior Plate Glass Coverage: *

None

$5,000

Would you like to add Business Income coverage? *

If you have a covered claim this coverage reimburses you after the waiting period for loss of income to keep your business running. (PLEASE NOTE THAT HOME OFFICE LOCATIONS ARE INELIGIBLE) This coverage is location specific.

Yes

No

If Yes, what limit of Business Income coverage would you like?

$10,000

$20,000

$30,000

$40,000

$50,000

Would you like to add Extra Expense coverage? *

(Includes Rental Value)(PLEASE NOTE THAT HOME OFFICE LOCATIONS ARE INELIGIBLE) If you have a covered claim, this coverage reimburses you after the waiting period for business expenses to keep your business running such as rent on another location. This coverage is location specific.

Yes

No

If Yes, what limit of Extra Expense coverage would you like?

$10,000

$20,000

$30,000

$40,000

$50,000

I understand and agree that a business continuation plan must be received in order to bind this coverage.

A business continuation plan is a written plan with steps to get your business back up and running after damages to your space prevent you from operating your business.

I understand and agree

I understand and agree that a 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 and agree

Locked Vehicle Warranty - The policy has a Locked Vehicle Warranty, which states there is NO coverage for equipment stolen from an UNLOCKED vehicle. Do you want to remove this warranty and thus add back coverage for equipment stolen from an unlocked vehicle for an additional 10% charge? *

Yes

No

Will you ever leave any equipment in your vehicle unattended? *

Yes

No (If you select "No", please skip down to DISCLAIMERS & SIGNATURE SECTION)

Does this equipment have a GPS tracking device?

Yes

No

If Yes, does the tracking device signal send to a monitored, remote device or security system?

Yes

No

Does the vehicle have an alarm system?

Yes

No

Where will the vehicle be parked when left unattended?

Check all that apply

City Street

Residential Street

Residential Garage (private home)

Residential Shared Garage (i.e. apartment complex)

Parking Garage

If you checked "Parking Garage", please also check all that apply to the parking garage below:

WIth 24 Hour Security Guard and Surveillance

With limited Surveillance

Restricted Access (Key Card)

Fenced

Gated

Lighted

Not Guarded

No Lot Attendant

Other

How frequent will you leave your equipment in an unattended vehicle?

Mark all that apply

Only if it's an emergency or rare situation when I cannot store it anywhere else

For short periods of time (less than 30 minutes) including for food and bathroom breaks

For hours at a time, but not overnight

For days at a time, including overnight

All the time, including storing it in my vehicle

Other frequencies

I UNDERSTAND AND AGREE THAT THIS QUOTE IS FOR EQUIPMENT COVERAGE AND DOES NOT APPLY TO VEHICLES, LIABILITY INSURANCE OR WORKERS COMPENSATION COVERAGE. *

I UNDERSTAND AND AGREE

I UNDERSTAND AND AGREE THAT IF I TAKE MY EQUIPMENT TO THE COUNTRY OF MEXICO, THERE IS AN AUTOMATIC SUB-LIMIT (CAP OF COVERAGE) OF $25,000 TOTAL. *

I UNDERSTAND AND AGREE

I UNDERSTAND AND AGREE THAT COVERAGE IS WORLDWIDE EXCEPT FOR COUNTRIES WITH US SANCTIONS. *

I UNDERSTAND AND AGREE

I UNDERSTAND AND AGREE THAT MY POLICY HAS A LOCKED VEHICLE WARRANTY. THIS MEANS THAT THERE IS NO COVERAGE FOR THEFT FROM AN UNLOCKED VEHICLE UNLESS I ELECT TO REMOVE THIS WARRANTY FOR AN ADDITIONAL 10% OF MY PREMIUM. *

I UNDERSTAND AND AGREE

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. *

I UNDERSTAND AND AGREE

TODAY'S DATE *

MM

DD

YYYY