Equipment/Liability Insurance Application
|
| |
|
| Business Name * Legal
Entity *
|
| Mailing Address *
City *
State *
Zip
|
| Contact Name Phone *
|
| Fax * Email *
Web Site
|
| Business Location (If different than above) -
Note: If more than one permanent location, please schedule on separate
sheet. |
|
| Primary Business Location is * Construction *
|
| Do You have Central Station Alarm * Year Built *
|
| Sprinklered? * # Floors In Building *
Square Footage of Studio *
|
| If Building Over 30 Years Old, when were electrical,
roof, heating system, and plumbing last updated? |
|
What is the value of Business Personal Property owned by the applicant.*
Including but not limited to: cameras, acessories, editing equipment,
furniture, and fixtures etal.
(BPP) |
Estimated Replacement Value *
Value of that portion of amount shown for question #4 that leaves your
premises.
(Off Premises) |
| Estimated Annual Sales * |
|
| Note Specific events/jobs you videotape/photograph. |
|
| Number of Photographers *
Number of Videographers *
|
| List details and amounts paid to your business for
any property or liablity claims in the last 3 years. If none, please
indicate. |
|
| Do you currently carry: |
|
| Equipment Insurance * General Liability Insurance *
Errors and Omissions Insurance *
|
| If Yes: Name of Insurance Carrier
Expiration Date
|
| Has any company refused or cancelled your insurance? *
If yes, please list details below |
|
| Do you have any Aerial Activities * |
|
| Any Underwater Activities? * |
|
| If Coastal, Distance From Beach |
|
| Years In Business * |
|
| Do you Rent your equipment to others?* |
| Are you in any way involved in Television Production? *
If yes, list details below. |
|
Wm. F. Buell, Inc.
621 E Park Ave.
Libertyville, IL 60058-2904
Fax: 847-367-7549
Should you have any questions, please call:
1-800-842-8355
ANY PERSON KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY
OR
OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING FALSE
INFORMATION
FOR THE PUPOSE OF MISLEADING INFORMATION CONCERNING ANY
FACT, MATERIAL
THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS
A CRIME.
|
| Applicant Name * Title *
Date * |
| |
|