1Policy Holder Information2Policy Term3Aditional Information & Digital Signature Policy Holder InformationFull Legal Name of Policy Holder*(As it should appear on insurance policy) Contact First Name* Contact Email* Last Name* Phone*Website FaxMailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Please describe your business operation* Have you ever had an equipment claim in the last 5 years?* Yes No Please describe all claims including date, payout, and loss details.Claim #1Claim #2Claim #3Where do you store your equipment the majority of time?* Does this place 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?* Yes No Do you ever travel with your equipment to Mexico?* Yes No Does any of your equipment go under water?* Yes No Is it in a waterproof protective case? Yes No Policy TermPlease select one of the following coverage options:* I need a SHORT-TERM POLICY (1 day to 11 months) coverage for RENTED Equipment (not including automobiles) I need an ANNUAL POLICY to cover at least one of the following Equipment types: Owned Production Equipment, Owned Sports, Leisure & Recreation Equipment, Owned Musical Instruments & Sound Equipment, Business Personal Property, Tenant Improvements & Betterments, Rented Equipment from Others Short-Term Coverage: Policy Terms 1 Day to 11 Months - Rented Equipment Coverage Only (No Automobiles)Rented Equipment from Others Limit (Replacement Value, including sales tax, of all equipment being rented) Rental Pick Up Date MM slash DD slash YYYY Rental Return Date MM slash DD slash YYYY Description of equipment being rented Continuing Rental Fees Coverage(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 Currently the policy has a Locked Vehicle Warranty. This means there is no coverage for theft from an UNLOCKED vehicle unless you elect to remove this warranty for an additional 10% of the premium. Would you like to remove this warranty for an additional 10% charge? Yes No Annual Coverage: Policy Term 12 Months - All Eligible Coverages and Options Available (No Automobiles)1. Please complete. At least one limit is required belowEquipment Type Replacement Value (Include sales tax) If none, enter 0 Description of Equipment (If none, please type "NA")Owned Production EquipmentCameras, camera equipment, sound, audio visual, lighting and grip equipment, communications equipment, portable electric equipment, editing and projection equipment, office personal property, generators, mechanical effects equipment, props, sets, wardrobe, event equipment, theatrical equipment, computer equipment including desktops,laptops and monitors, and all similar personal property and related production and entertainment equipment.Owned Production Equipment Description Owned Sports, Leisure & Recreational EquipmentSporting goods and equipment, gym and fitness equipment, business personal property, tenant improvements, sport event property, race timing machines, racing chips, banners, office personal property, ROTC related equipment, and any related Sports & Recreational equipment.Owned Sports, Leisure & Recreational Equipment Description Tenant Improvements & BettermentsFixtures, alterations, installations, or additions that become part of a building that you do not own and cannot be legally removed. The tenant improvements and betterments were paid by you and had them installed or personally installed. This does not cover any landlord improvements to the rented space.Tenant Improvements & Betterments Description Business Personal PropertyOffice Furniture, lockers, rugs, lamps, telephones any other similar business personal property.Business Personal Property Description Owned Musical Instruments & Sound EquipmentMusical Instruments, sound equipment, vintage musical instruments, similar personal property, office personal property, and other related musical equipment.Owned Musical Instruments & Sound Equipment Description Rented Equipment from Others (Maximum value at any one time)Any of the above equipment classes rented for use not including tenant betterments and improvements.Rented Equipment from Others Description 2.Do you rent any of your owned equipment to the sole custody of others (unaccompanied by you or your employees)? Yes No 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)?3.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 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 4.For equipment you own, is any single item valued at $5,001 or more (replacement cost including sales tax)? Yes No Is the equipment value included in the limits you entered into the Equipment Type Chart (Question 1)? Yes No Please list below ALL single items valued at $5,001 or more showing Make, Model, Serial #, and Replacement Cost (including sales tax). Owned items that are valued at $5,001 or more that are not listed will not be covered under the policy.5.Rental Reimbursement Coverage - only available with Owned Equipment CoverageIf you have a covered claim, this coverage reimburses your rental fees for equipment rented to continue your business operations. None $2,500 $5,000 $10,000 $25,000 6.Continuing Rental Fees Coverage. Only available with Rented Equipment from Others CoverageIf 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 time deductible from the time the claim is reported in writing to the insurance agent or carrier. None $2,500 $5,000 $10,000 $25,000 7.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 8.Interior/Exterior Plate Glass Coverage.This covers exterior or interior plate glass installed by either you or your landlord at your business location. None $5,000 (additional premium $50.00) 9.Business Income and Extra Expense (other than rental value).This covers the loss of business income and extra expenses as a result of a covered claim. This does NOT include 'rental value' which is loss of rental income your landlord incurs. This optional coverage is tied to the scheduled location only, which means the claim has to occur at the scheduled location. None Limit Requested Enter Limit (Maximum Limit $50,000):Please enter a number less than or equal to 50000.Please schedule the location(s) for the requested Business Income Coverage (description, location address, city, state, zip):Location 1: Location 2: I understand that Business Income and Extra Expense is tied to a scheduled location, which means the claim has to occur at the location(s) listed above.* I understand that Business Income and Extra Expense is tied to a scheduled location, which means the claim has to occur at the location(s) listed above. Business Continuation PlanA business continuation plan would be a written document with a plan of action to get your business up and running to minimize down time based on the following 4 key elements. 1-Office Space. 2-Power for this Space. 3-Connectivity (internet/phone). 4-Technology/Hardware Systems. I understand a Business Continuation Plan must be received in order to bind this coverage. I understand 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 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. 10. Locked Vehicle WarrantyThis policy has a Locked Vehicle Warranty, which states there is NO coverage for equipment stolen from an Unlock vehicle. Do you wan to remove this warranty and thus add back coverage for equipment stolen from an Unlock vehicle for an additional 10% charge?This covers exterior or interior plate glass installed by either you or your landlord at your business location. Yes No Aditional InformationHow did you hear about us?* Disclaimers & Signature I understand that this quote is for equipment coverage and does not apply to vehicles, liability insurance, or workers compensation coverage. I understand 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 that coverage is worldwide except for countries with US Sanctions. I Understand that minimum premium is fully earned at policy inception. I understand that if the policy is cancelled, all minimum premium is fully earned and will not be refunded. I understand 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 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. Applicant Name:* PhoneThis field is for validation purposes and should be left unchanged. Δ
