EmeryWebb of Signature Program Quote Request 4.0

Emery & Webb Musical Instruments Signature Insurance Program

Quote Request (Powered by Anderson Musical Instrument Insurance)
Source
Full Name*

First NameLast Name
E-mail*

Confirmation Email
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred Contact Number*
Alternative Contact Number
Referred By
How did you hear about us?

Preliminaries
Instrument type*
How often is your instrument away from your premises?*
Have you ever previously insured your instruments*
Are you the primary user of this instrument *
Who is the primary user?*
Is the primary user a minor?*
Grade*
Do you ever take your instrument(s) on gigs or tour?*

Location and Storage of Instrument(s)
When your instruments are not being played, are your instruments located at the insured address noted on the contact screen?*
Tell us about how and where your instruments are stored:*
When your instruments are stored, how are they protected from the sun, excessive humidity, theft, fire, water damage, accidental dropping, earthquake protection, etc:*
Please provide the address where your instruments are stored*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Off-Premises Information
Please provide make and model of the case used, along with any additional safeguards, to protect your instrument(s) during transport.
What is this individual's experience in transporting instruments?
Where are your instruments stored when not being played and are they protected from household pets and young children?
Who is responsible for your instruments when you are away from your premises and what protective safeguards are in place, if any?

Playing Out - Tour and Gig Information
What is the approx. number of tours, gigs, services away from your premises per year?
How often are your instruments away from your premises, e.g. when gigging, touring, providing services.
Please describe typical venues where you play as well as the extent of travel, especially when on tour, if applicable:
What is the average number of instruments generally taken on gigs/tours?
Average total value of instruments taken tour?

About You - Background and Musician Association/Organization Memberships
Please rate your level of Musical Instrument proficiency
Where do you customarily play your instrument(s)?
Number of performances annually
Are you a member of any Musician Associations, Organizations or Orchestras? Y / N - If yes, please provide details as discounts may be available

Instrument details

Prior Insurance coverage Information
Previous insurance carrier and reasons for change
Cost/rate for previous coverage
Previous deductible
Prior Claim History (if any)

Additional Insured's / Lienholders
Are there any additional insured or lienholders?*
Additional Insured / Loss Payee Name*
Additional Insured / Loss Payee Address*
Lienholder Loan Number (if applicable)

Certifications / Disclosures / Warrants
1. I ACKNOWLEDGE THE ANSWERS AND INFORMATION PROVIDED BY ME ARE TRUE AND ACCURATE.

2. STATEMENT OF ZERO PRIOR DAMAGE: I/we, hereby warrant that there have been no prior losses, accidents, incidents, unrepaired damage or any circumstances that may have occurred prior to the date that coverage first becomes effective with Anderson, such pre-existing condition would not be covered under this policy.

3. NO COVERAGE FOR NORMAL WEAR AND TEAR OR MAINTENANCE: I understand and acknowledge that there is no coverage provided under this policy for normal wear and tear and maintenance.

4. FRAUD NOTICE: I acknowledge that any person who knowingly and with intent to defraud any Insurance Company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

5. Payment of the annual premium and policy fee is fully earned and non-refundable should I cancel this coverage before the expiration of the initial annual coverage term.

6. COMMISSION AND ADMINSTRATIVE FEE DISCLOSURE: Anderson Musical Instrument Insurance Solutions, LLC receives a sales commission in the form of a fixed percentage of the premium and annual policy fee paid by me for costs associated with the issuance of my policy by Anderson.
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Emery & Webb Musical Instruments Signature Insurance Program

Preliminaries

Location and Storage of Instrument(s)

Off-Premises Information

Playing Out - Tour and Gig Information

About You - Background and Musician Association/Organization Memberships

Instrument details

Prior Insurance coverage Information

Additional Insured's / Lienholders

Certifications / Disclosures / Warrants