CONTRACTORS EQUIPMENT
Insured:
Street address:
City:
State	Select Maryland Pennsylvania Virginia Delaware New Jersey Washington, DC				Zip:
Expiration Date:
Type of Business:
Years Experience:
Years in Business:
Prior Carrier:
Does Agent know Personally:	Select Yes No
Current Premium:
Current Deductible:
What other coverages
do you write for insured:
Prior Losses:
(Please provide details)
Logging risks contracted with:
Maintenance Program:	Select Yes No
Please provide details of
maintenance program:
Overall Financial Condition:	Select Excellent Good Fair Poor
Agents Recommendation:
Unit #1 - Year:
Unit #1 - Make & Model
Unit #1 - Serial Number:
Unit #1 - Limit of Insurance:
Unit #1 - Deductible:
Unit #1 - Loss Payee Info:
Unit #2 - Year:
Unit #2 - Make & Model
Unit #2 - Serial Number:
Unit #2 - Limit of Insurance:
Unit #2 - Deductible:
Unit #2 - Loss Payee Info:
Unit #3 - Year:
Unit #3 - Make & Model
Unit #3 - Serial Number:
Unit #3 - Limit of Insurance:
Unit #3 - Deductible:
Unit #3 - Loss Payee Info:
Unit #4 - Year:
Unit #4 - Make & Model
Unit #4 - Serial Number:
Unit #4 - Limit of Insurance:
Unit #4 - Deductible:
Unit #4 - Loss Payee Info:
Unit #5 - Year:
Unit #5 - Make & Model
Unit #5 - Serial Number:
Unit #5 - Limit of Insurance:
Unit #5 - Deductible:
Unit #5 - Loss Payee Info:
Agency Name:
Agency Address:
Agency Phone:
Agency Fax:
Agency Contact Name:
Contact E-Mail Address:
Any other information you would like us to know about this risk:
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