Emailing your request will allow us to provide you with accurate and timely turnaround. Please be sure to fill in all of the information requested to process the request. Please note that completing this application does not bind or guarantee that insurance coverage will be quoted.

REQUEST FOR INSURANCE COVERAGE
Your Corporate Name(s):

Location Addresses:

Contact Name:
Title:
Telephone:
Cell Phone:
Fax:
Email Address:
CONFIDENTIAL REVENUE BREAKOUT FOR RATING PURPOSES
Crane rental with operator:$
Crane rental without operator:$
Pure millwright work:$
Equipment rental with operator:$
Equipment rental without operator:$
Other:$
LISTING OF EQUIPMENT
Year	Make/Model/Type	Capacity	Value






LISTING OF EQUIPMENT
Insurance Company Name:
Agent Name:
General Liability Exp Date:
Equipment Exp Date:
Automotive Exp Date:
Workers' Comp Exp Date:
Property Exp Date:
Umbrella Exp Date:
PLEASE DETAIL EQUIPMENT & GENERAL LIABILITY CLAIMS OVER THE PAST 5 YEARS
Date	Description of Claim		Amount



I certify under penalty of law that the above information is correct.
Please enter your initials here