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Quotation Request Form - Equipment Breakdown Broad Form

Please select the location to which you would like to send your quote:

Insured:

Date: / / (mm/dd/yyyy)

Mailing Address:

Contact Name:

Contact Phone No: () -

May BI&I Contact Insured? Yes No

Location No. 1

Address of Location:

Occupancy:

P.D. Values: $

Building: $

Equipment: $

Stock: $

Office: $

Tenant Improvements: $

EDP: $

Other: $

B.I. Values: $

Prospect Information

Loss History (last 5 years): Yes No

If Yes:

Date of Loss: / / (mm/dd/yyyy)

Object:

Amount paid: $

Existing Broker:

Existing B&M Carrier:

Existing Property Carrier:

Proposed Coverage

Coverage/description	Limit of liability	Deductible/Waiting period
Property Damage	$	$
Business Interruption
Loss of Profits:	$
Rent/Rental Value:	$
Gross Earnings:	$
Actual Loss Sustained:	$
Other:	$
Extra Expense:	$
Spoilage:	$

Product Stored:

Other Coverages

Automatic Coverage: $

Demolition and Increased
Cost of Construction: $

Errors and Omissions: $

Hazardous Substance: $

Water Damage: $

Ammonia Contamination: $

Professional Fees: $

Data: $

Service Interruption:

Denial of Access:

Quote Includes: Production Machinery Electronic Equipment

Endorsement(s) Required:

Existing Policy No:

Anniversary Date: / / (mm/dd/yyyy)

Date Quotation Required: / / (mm/dd/yyyy)

Broker/Reinsurance co. Information

Quotation Required by: Broker Reinsurance Co.

Name:

City:

Contact Person:

Phone No.: () -

Fax No.: () -

E-mail:

Notes: