Insurance Pumps & Motor Application

INSURANCE PUMPS & MOTOR APPLICATION

Applicant / Insured Information

Applicant Name:

Individual Partnership Corporation LLC Other

Equipment Location & Description

Location Name / Facility:

Number of Pumps / Motors to be Insured:   Main Use of Equipment:

Provide details for each pump or motor. Attach additional schedules if necessary.

Policy & Coverage Requested

Property Damage (Direct Physical Loss) Equipment Breakdown (Mechanical & Electrical) Business Interruption / Gross Earnings Expediting Expenses Transit Coverage

Protective Safeguards & Maintenance

Indicate safeguards in place at the insured location:

Scheduled maintenance contract in force Automatic shutdown / trip protection Surge protection / VFD protection Fire protection / sprinklers

Loss History & Claims

Any losses or claims involving pumps, motors or related equipment in the past 5 years?    Yes No

Exclusions & Limitations

The applicant acknowledges that coverage is subject to policy terms, conditions and exclusions. Typical exclusions applicable to pumps and motors include, without limitation:

- Loss or damage caused by gradual deterioration, wear and tear, corrosion, rust, erosion, scaling, freezing, or overheating due to lack of maintenance;
- Loss or damage resulting from inherent defect, latent defect or faulty design where the equipment has not been installed or maintained in accordance with manufacturer specifications;
- Damage arising out of mechanical breakdown exacerbated by negligent operation, unapproved modification, or failure to follow shutdown procedures;
- Nuclear hazard, war, governmental action, and willful acts of the insured;
- Losses excluded under the policy for pollutant release and contamination except as explicitly endorsed.

Beneficiary / Loss Payee

Loss Payee / Mortgagee Name:

Declarations & Certification

The undersigned applicant certifies that the information contained in this application is true, complete and submitted for the purpose of obtaining insurance. The applicant understands and agrees that:

1. Coverage, if issued, will be subject to the terms, conditions, exclusions and endorsements of the policy issued to the insured. Premium is based upon the information provided and is subject to adjustment upon inspection or audit. Any material misrepresentation or omission may void coverage from inception.

2. The insurer is authorized to make inspections of the described property and to obtain records necessary to verify exposure and history. The applicant agrees to permit scheduled maintenance and protective devices as a condition of coverage where indicated.

3. In the event of a loss, the insured will promptly notify the insurer and take reasonable steps to protect property from further damage. The insured acknowledges subrogation rights and agrees not to waive such rights without insurer consent in writing.

Authorization

By signing below, the applicant authorizes the insurer to obtain and use loss history, underwriting and inspection reports. The applicant acknowledges that completion of this form does not bind coverage. Coverage, if offered, will be effective only upon issuance of the policy and payment of premium in accordance with the insurer's requirements.

Sign Now