Equipment Breakdown Application
Enter in the information below to submit an application for Equipment Breakdown coverage.
Click Here to Download the Required SOV Template
Inception Date
*
-
Month
-
Day
Year
Expiration Date
*
-
Month
-
Day
Year
Policy Holder Details
Named Insured:
*
Mailing Address of Insured
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the State of filing?
*
ex: FL, NC, NY, etc.
Do you want to add an Additional Insured?
*
Yes
No
Additional Named Insured:
*
Full Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you want to add an Additional Insured?
*
Yes
No
Additional Named Insured:
*
Full Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you want to add an Additional Insured?
*
Yes
No
Additional Named Insured:
*
Full Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you want to add a Loss Payee?
*
Yes
No
Loss Payee - Full Name:
*
Full Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you want to add a Loss Payee?
*
Yes
No
Loss Payee - Full Name:
*
Full Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you want to add a Loss Payee?
*
Yes
No
Loss Payee - Full Name:
*
Full Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Equipment Inspection Contact Details
Please outline an individual contact associated with the risk who can serve as an Equipment Inspection Contact. If a piece of equipment is determined to be overdue on any inspections, the carrier may coordinate an inspection at no cost to the Insured.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Title/Position
*
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Business Information
Select Occupancy Type:
*
Please Select
Agriculture
Air
Communication (Radio and TV)
Construction
Education
Emergency Response Services
Entertainment and Recreation
Flood Control
Food and Drug Processing
Gasoline Service Station
General Services
Group Institutional Housing
Highway
Hotels - Large
Hotels - Small & Medium
Light Fabrication and Assembly
Multi-Family Dwelling Condominium Unit Owner
Multi-Family Dwelling Homeowners Association
OTHER
Parking
Permanent Dwelling (Multi-Family Housing)
Personal and Repair Services
Professional, Technical, and Business Services
Railroad
Religion and Non-profit
Rental General Commercial
Restaurants
Retail Trade
Sea/Water
Telephone & Telegraph
Temporary Lodging
Universities and Colleges
Wholesale Trade
If "Other" Please Explain - PLEASE NOTE THAT ALL 'OTHER' SUBMISSIONS ARE REFERRED:
*
There is Medical diagnostic equipment with a single piece of equipment valued at more than $500,000:
*
Yes
No
The Insured is engaged in the generation, transmission, and/or distribution of electric energy for use or sale at any location:
*
Yes
No
The Insured is engaged in the generation, transmission, and/or distribution of electric energy for use or sale at any location:
*
Yes
No
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Next
Location Details
PLEASE BE ADVISED: All submissions must use the dedicated SOV template linked below. Please download the document, fill in all required details, and drop the completed document in the delivery box below.
Click Here to Download the Required SOV Template
Download the SOV Template above, complete it, and upload your completed file here.
*
Browse Files
Drag and drop files here
Choose a file
PLEASE ONLY UPLOAD/SUBMIT SOV FILES THAT FOLLOW THE MARKET"S REQUIRED FORMAT. THE FILE IS LINKED ABOVE.
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Has the Insured had any Equipment Breakdown Losses in the past 3 years?
*
0
1
2+
Please Enter the Total Loss Amount $
*
Please only include Equipment Breakdown Loss Value.
What is the Deductible required?
*
Please Select
$1,000
$2,500
$5,000
$10,000
$25,000
$50,000
$75,000
$100,000
$250,000
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Next
Agent Information (Your Information)
Name
*
First Name
Last Name
Agency Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Form
Should be Empty: