Insurance Gage Application

INSURANCE GAGE APPLICATION

Applicant / Insured Information

Date of Birth / Legal Entity Formation Date:   Tax ID / SSN (last 4 digits if privacy required):

Policy Details Requested

Policy Period Requested: From to .

Gage Schedule and Valuation

Coverage Options (select as applicable)

Property Damage (including impact, fire)

Theft and Vandalism

Accidental Damage in Use

Transit (loading, unloading, while in transit)

On-site Calibration / Certification Loss

Rental Replacement Costs

Loss Payee / Beneficiary

Loss Payee Name:

Relationship to Insured:   Percentage of Proceeds:

Inspection, Maintenance and Calibration

Are gages routinely inspected and calibrated per manufacturer's recommendations?    Yes    No

Claims History

Attachments Checklist

Detailed inventory / schedule of gages

Current calibration certificates

Photographs of equipment (if available)

Copy of prior insurance policy declarations (if renewal)

Exclusions (Representative)

The following are standard exclusions unless specifically endorsed: wear and tear, gradual deterioration, inherent defect, mechanical breakdown unless resulting from a covered peril, nuclear hazard, war, and fraudulent or intentional acts by the insured. Coverage for willful neglect, dishonest acts, or inventory shortage requires specific underwriting and endorsement.

Declarations and Applicant Certification

By signing below, the Applicant represents that the information provided in this application is true and complete to the best of the Applicant's knowledge. The Applicant authorizes the insurer and its representatives to inspect the described gages, verify calibration records, and obtain loss history. The Applicant understands that any material misrepresentation or omission may be grounds for declination of coverage or rescission of the policy and may be subject to penalty under applicable law.

The Applicant further agrees that any policy issued in reliance upon this application will be subject to all terms, conditions, limitations and exclusions contained in the policy form and endorsements. Submission of this application does not bind the insurer to issue coverage nor bind the Applicant to accept coverage until a binder or policy is issued in writing.

The Applicant authorizes release of loss or claim information and calibration/maintenance records to the insurer or its authorized representative for underwriting and claim handling purposes.

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