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Contractors Choice Equipment Product (Access E&S Insurance Services)

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CCE APP 10/10
page 1 of 3
1. Applicant’s name: __________________________________________________________________________________________________________
Form of business: q Individual q Corporation q Partnership q LLC q Other ____________________________
2. Applicant’s address: ________________________________________________________________________________________________________
Phone number: ______________________________________________________ E-mail address: ______________________________________
Web address: _______________________________________________________
3. Applicant’s operations: q Grading/Paving/Excavating q Landscaping q Sand and gravel hauler
q Plumbing q Roofing q Irrigator
q Tree trimmer q Farming q General contracting
q Other (describe): _______________________________________
4. Applicant’s years in business: _________________________________________ Applicant’s years of experience: ________________________
5. Has applicant or majority partner filed for bankruptcy in the past five years? q Yes q No
6. Has this coverage been cancelled or nonrenewed, including for non payment, in the past three years? q Yes q No
7. Schedule of Property - Description of owned and leased equipment:
*Attach another page if necessary Miscellaneous owned tools and equipment (Per item value of less than $1,000)
All Covered Property
8. Does insured desire coverage for equipment borrowed and rented from others for an additional charge?
  q No q $25,000 per piece q $50,000 per piece
a. Estimated annual rental expense: (Do not include expense for scheduled equipment) $ _________________________________________
9. Deductible
q $1,000 q $2,500 q $5,000 q $10,000
(Mandatory $2,500 if any one piece of equipment has value between $50,000 - $99,999; $5,000 if $100,000 or more)
10. Valuation
q Actual cash value q Replacement cost - for equipment five model years old or newer
(80% coinsurance) (90% coinsurance)
UNDERWRITING AND RATING INFORMATION
11. How many contractor’s equipment losses has the insured incurred in the past three years? _________________________________________
Total incurred amount? $ _____________________ Details: _______________________________________________________________
12. Does the insured perform/operate any mining, logging, rigging, salvage, scrap, recycling center, dredging, quarrying,
landfill, underground operation or custom harvesting? q Yes q No
13. Are there any asphalt plants, cranes, conveyors or rock drills on the schedule of equipment? q Yes q No
Item Manufacturer Model Number Model Year Serial Number Description Limit of Insurance
1 $
2 $
3 $
4 $
5 $
6 $
7 $
8 $
9 $
10 $
$
$
CONTRACTORS’ CHOICE EQUIPMENT PRODUCT WARRANTY APPLICATION
All questions must be answered and application must be signed by the applicant.
Contractors’ Choice Equipment Product
USLI.COM
888-523-5545
14. Are there any scheduled vehicles licensed for over-the-road use? q Yes q No
15. Is any equipment mounted on barges or used on or adjacent to water in any way? q Yes q No
16. Any work performed at nuclear facilities, chemical or petroleum plants? q Yes q No
17. Does the insured sell, lease, loan or rent equipment to others? q Yes q No
18. How is the scheduled equipment stored after working hours?
q All scheduled equipment, after working hours, may at times not be in an area that is fully fenced and locked or in a locked building.
q All scheduled equipment, after working hours, is stored in an area that is fully fenced and locked.
q All scheduled equipment, after working hours, is stored in a locked building.
19. Is all equipment equipped with a Lo-Jack system? q Yes q No
20. Prior carrier ______________________________ Policy term______________ to ____________ Premium $ ______________________________
21. Loss payee _______________________________________________________________________________________________________________
Applicant’s Warranty Statement: The undersigned represents to the best of his/her knowledge and belief the particulars and statements set
forth are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The
undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may
render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may
withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The signing of the Application does
not bind the undersigned to purchase the insurance, nor does the review of the Application bind the Company to issue a policy. It is
understood the Company is relying on the Application in the event the Policy is issued. It is agreed that this Application, including any material
submitted therewith, shall be the basis of the contract should a policy be issued, and may be attached to and become part of the policy.
Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of
the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the
admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
CCE APP 10/10
page 2 of 3
Fraud Statement (All Other States): 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 is guilty
of a crime and may be subject to fines and confinement in prison.
Authorization: I/we authorize the company to provide the National Equipment Register (NER) with the information provided in response to
Questions 1, 2 and 7 of this application for purposes of registering insured equipment in the NER theft detection and tracking program.
Applicant’s signature: ____________________________________________ Title ________________________ Date: _____________________
(Owner, Principal, or Partner)
Broker’s signature: _______________________________________________ Date: _____________________________________________________
Address: ______________________________________________________________________________________________________________________
Some states require that we have the name and address of your (insured’s) authorized agent or broker.
Name of authorized agent or broker: _____________________________________________________________________________________________
Address: ______________________________________________________________________________________________________________________
Mail completed application through local agent or broker to:
______________________________________________________________________________________________________________________________
CCE APP 10/10
page 3 of 3
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Completed 8 January 2021

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