CONTRACTORS EQUIPMENT APPLICATION

QUESTIONS TO BE ANSWERED BY APPLICANT

1.Name of Applicant:
2.Mailing address:
3.City: State: Zipcode:
4.How long in business:
5.In what territories is the equipment to be used?
6.Purpose(s) for which equipment is used?
7.a) Location to which equipment is returned when not in use.(ie insured's residence,business address, storage lot, etc.)

b) Is equipment housed?
c) Is the equipment in the open? If so, estimate maximum value any one time. $
d) If equipment is in the open, is area fully enclosed by a fence?
e) Is the equipment ever left on the job site?
If yes, what are the burglary protections?
8.a) Does applicant do any road building or other work in mountainous areas?
b) Does applicant do any dynamiting or work at job sites where others might do dynamiting work?
c) Will the equipment be used over water, such as bridge building or on barges,bulkhead or jetty work?
9.Has the applicant sustained any losses during the past five years which would have been covered under this form of insurance if the applicant had carried such a policy? If so, list all claims
10.Was insurance carried?
11.If so, company insuring same.
12.Has Lloyd's or any Company ever cancelled insurance for applicant?
13.Has insurance ever been refused? If so, give full particulars.
14.Who has previously insured the applicant's equipment?
15.Schedule:
ItemSerial # Date of
Purchase
Actual Cash
Purchase
Price Value
16.What items above loaned or rented to the insured?
17.a) Will any equipment be rented out?
b) If so, is the equipment driven solely by employees of the Assured?
18.How often is the equipment serviced and by whom?
19.Is there any other material fact, within your knowledge, regarding this proposal of insurance, which should be submitted to the Insurers form consideration?
20.Coverage required:
21.Flood or landslip exposure?
22.Loss Payable Name & Address:
23.Does any one item of equipment have a mortgage of more than 75% of the value If yes, please list all items with a 75% or more mortgage

Date:______________________Signature of Applicant: __________________________________

QUESTIONS TO BE ANSWERED BY BROKER
1. What is the construction of the Assured's premises and what is the Fire Contents Rate?
2. Do you know the Applicant personally? If so, for how long?
3. Did you receive the order direct from the Applicant?
4. Do you handle other Insurance for Applicant?
5. Do you recommend Applicant?

Signature of Agent/Broker:____________________________________________________

Agent
Agency:
Address:
City: State: ZipCode:
Phone: Fax: