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EQUIPMENT INSURANCE QUOTE
We provide insurance coverage for Minnesota and Wisconsin only

To obtain a FREE, no obligation quote for your Equipment, fill out the form below and we will contact you. In order to provide an accurate quote we would ask that you please provide us with the following information at the time of quoting. Information necessary to the quoting process may be collected from consumer reporting agencies, inspection services and motor vehicle departments. This information is available to the insurance companies who provide the quotes. *Required infomation

Name: *
Address:
City:
State:
ZIP:
Home Phone: *
Email: *
Work Phone:
Cell Phone:
Present Equip Insurance Co:
Renewal Date of Curret Policy:
Drivers License No.: *
Many of the companies we represent require this information prior to providing a firm quote. To provide an accurate quote we need to ask questions about yourself and members of your family. The information collected enables us to receive information from consumer reporting agencies, motor vehicle departments, and inspection services. This information is available to the insurance companies who provide the insurance rates used in the quoting process.

UNIT #1
Year:   Make:   Model:
Serial/Vin No:
Current value of unit:
Lienholders Name:
Lienholder Address:
City:   State:   ZIP:

UNIT #2
Year:   Make:   Model:
Serial/Vin No:
Current value of unit:
Lienholders Name:
Lienholder Address:
City:   State:   ZIP:

UNIT #3
Year:   Make:   Model:
Serial/Vin No:
Current value of unit:
Lienholders Name:
Lienholder Address:
City:   State:   ZIP:

UNIT #4
Year:   Make:   Model:
Serial/Vin No:
Current value of unit:
Lienholders Name:
Lienholder Address:
City:   State:   ZIP:

UNIT #5
Year:   Make:   Model:
Serial/Vin No:
Current value of unit:
Lienholders Name:
Lienholder Address:
City:   State:   ZIP:

UNIT #6
Year:   Make:   Model:
Serial/Vin No:
Current value of unit:
Lienholders Name:
Lienholder Address:
City:   State:   ZIP:

UNIT #7
Year:   Make:   Model:
Serial/Vin No:
Current value of unit:
Lienholders Name:
Lienholder Address:
City:   State:   ZIP:
Please list by date all dollar amounts claimed/paid for any and
all losses associated with your heavy equipment over the past 5 years.
Include a brief description of each loss:
If you have WorkComp coverage please provide us with
your current experience modification facts:
Comments:
  
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