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Boiler & Machinery Application
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Contact Person

First Name *
 		Last Name *
Home Phone
 		Home Fax
 		E-Mail *
 

Mailing Address (Only if different than business location)

Street Address
City
State
Zip
-
 

Business Information

Name *
 		DBA
Street Address *
City *
 		State *
 		Zip *
 -
Phone *
 		Fax
 

Insurance Information

Are You a Tenant or Owner:     Tenant   Owner
Type of Business:    Manufacturing     Non-Manufacturing
Square Footage of Location   Year Built
100% Building Replacement Value
$ 		Contents Value (Excluding Stock)
$
Annual 100% Business Interruption Value
$ 		Value of Perishable Goods
$
Value of Computer System
$ 		Include Ordinary Payroll?    Yes   No
$ If yes, List Value
Largest / Most Expensive Piece of Equipment:    Value: $ 
Boiler:    Yes   No
List of Equipment Breakdown Losses for the Last 5 Years: 
Type of Coverage Desired:  Basic Boilers & Pressure Vessles Only     Comprehensive     Comprehensive Including Production Machines
Current Insurance Carrier  Current Premium $
Property Insurance Carrier 
 

Notes

 

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