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TOOL AND EQUIPMENT APPLICATION SUPPLEMENT (Risk Placement Services, Inc.)

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TOOL AND EQUIPMENT
APPLICATION SUPPLEMENT
Name
Submission/Policy Number:
Proposed Effective Dates: FROM:
TO:
INLAND MARINE COVERAGE FOR INSURED'S/EMPLOYEES' TOOLS AND EQUIPMENT
Amount of coverage desired: $
Deductible per occurrence: $
YOU MUST SCHEDULE EVERY ITEM VALUED AT $1,000 OR MORE FOR WHICH COVERAGE IS TO APPLY.
Item #
Name of Owner and Item Description
Manufacturer
Serial Number
Value/Limit
Effective Dates
From - To
Prior Carrier Name
Policy Number
#
Losses
Loss Amount
Description of Loss
Prior Carrier
INSURANCE HISTORY AND LOSS EXPERIENCE
Yes
No
Has insurance company canceled or nonrenewed your policy is the last 3 years?
(Missouri Applicants - Do not answer this question.)
If yes, explain:
T-482 (6/14)
Page
of
© 2014 The Travelers Indemnity Company. All rights reserved.
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Completed 23 November 2020

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