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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:
Occupancy:
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 or Reinsurance Co.
Name:
City:
Contact Person:
Phone No.: ( )  -
Fax No.: ( )  -
E-mail:
Notes:

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