Insurance Equipment Application Document

Insurance Equipment Application Document

Applicant / Insured Information

Date of Birth:

Policy Details Requested

Policy Period From:   To: 

Equipment Schedule (List each item to be insured)

If additional items exist, attach a separate schedule with identical fields and mark as SCHEDULE A.

Coverage Selection

Select requested coverages (check all that apply). Selection does not bind coverage until a policy is issued in writing.

Exclusions — Please Read Carefully

The policy, if issued, will contain standard exclusions including, without limitation: wear and tear, gradual deterioration, inherent defect, rust or corrosion, loss due to wilful conversion or concealment by the insured, losses attributable to improper maintenance, commercial testing, nuclear hazard, war, and losses caused intentionally by the insured. No coverage exists for losses caused by intentional acts or for items not declared on the schedule.

Maintenance, Security & Inspection

The insured represents that all equipment listed is maintained in accordance with manufacturer recommendations and will be kept in the stated location(s). The insurer shall have the right to inspect the insured equipment at reasonable times. Failure to maintain or permit inspection may be grounds for declination, termination, or denial of a claim.

Beneficiary / Payee for Loss Proceeds

Provide the person or entity to which claim proceeds should be payable in the event of a covered loss. If secured by financing, state lender name and include clause in schedule.

Required Documentation Checklist

Attach copies of the following items with this application. Failure to supply required documentation may delay underwriting or result in declination.

Declarations, Representations & Consent

By signing this application, the applicant declares that all statements and particulars contained herein are true and complete to the best of the applicant's knowledge and belief. The applicant warrants that no material facts have been omitted or misstated. Material misrepresentation or omission may render any resulting coverage voidable ab initio.

The applicant grants the insurer the right to make inquiries and obtain records necessary for underwriting, including but not limited to inspection of equipment and verification of maintenance and ownership. The applicant authorizes release of claim information, if any, to other insurers or reinsurers as required for underwriting or claim handling.

The applicant agrees to indemnify and hold harmless the insurer and its representatives against any losses arising from false statements made in this application. Coverage, if issued, will be governed solely by the terms and conditions of the issued policy and endorsements; no coverage exists prior to issuance except as may be provided by a written binder issued by an authorized representative.

Fraud Warning & Certification

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance may be subject to criminal and civil penalties under applicable law, including but not limited to fines and imprisonment.

Certification: I certify that the information provided in this application is true, complete, and presented in good faith. I understand that this application, together with any attachments and the declarations page of the policy if issued, will form the basis of the insurance contract.

Signature and Authorization

Authorized Representative / Applicant (print name), Title and Contact Information must be provided. Signing this application binds the applicant to the certifications above.

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