Equipment Rental Application | Rented Equipment Insurance

Section 1 — Equipment Rental

Date

Applicant (full legal name of person to be insured *

Street Address

City

State

Zip

Telephone Number *

Email *

Date of Birth

s License No

State of Issuance

Expiration Date

Type

Carrier

Policy Number

Effective Dates

Type

Carrier

Policy Number

Effective Dates

Type

Carrier

Policy Number

Effective Dates

Type

Carrier

Policy Number

Effective Dates

You must fully and completely disclose any and all liability losses and attach additional pages if necessary [1]

You must fully and completely disclose any and all liability losses and attach additional pages if necessary [2]

You must fully and completely disclose any and all liability losses and attach additional pages if necessary [3]

What is your previous experience with equipment rental(s) of a similar type [1]

What is your previous experience with equipment rental(s) of a similar type [2]

What is your previous experience with equipment rental(s) of a similar type [3]

Name

Street Address

City

State

Zip

Telephone Number

Date of Birth

s License No

State of Issuance

Expiration Date

Previous experience with equipment rental(s) of similar type [1]

Previous experience with equipment rental(s) of similar type [2]

Name

Street Address

City

State

Zip

Telephone Number

Date of Birth

s License No

State of Issuance

Expiration Date

Previous experience with equipment rental(s) of similar type [1]

Previous experience with equipment rental(s) of similar type [2]

Name

Street Address

City

State

Zip

Telephone Number

Date of Birth

s License No

State of Issuance

Expiration Date

Section 2 — Page 2

Previous experience with equipment rental(s) of similar type [1]

Previous experience with equipment rental(s) of similar type [2]

s address

City

State

Zip

Start Date

Start Time

End Date

End Time

Company Name

Street Address

City

State

Zip

Type

Make

Model

Year

Value

Vin

Type

Make

Model

Year

Value

Vin

Type

Make

Model

Year

Value

Vin

Type

Make

Model

Year

Value

Vin

Silver: $25,000 per person, $50,000 per accident, $100,000 aggregate Yes

Gold: $50,000 per person, $100,000 per accident, $200,000 aggregate Yes

Platinum: $100,000 per person, $200,000 per accident, $400,000 aggregate Yes

Deductible

Other Yes

Applicant is submitting this application for a liability quote only

500 Yes

1,000 Yes

2,500 Yes

Other Yes

Section 3 — Representations And Warranties

Applicant

Agent/Broker

Signature

Print name

Submissions are routed to our service team for review. We use the information you provide only to prepare your quote.