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Inland Marine Equipment

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General Information
How did you hear about us? *
BIA Chamber of Commerce
Current Client Email
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Referral: Website:
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Named Insured: *
Contractor's License #:
Owner's Name: *
Contact's Name: *
Phone: *
Fax:
Cell:
Email Address: *
Preferred method of contact: *
Phone Fax Email Mail
Address Information
Mailing Address
Street: *
City: *
State: *
Zip: *
 
Premise Address
Street:
City:
State:
Zip:
Business Entity: *
Sole Proprietorship Partnership Corporation LLC Other:
Scheduled Equipment Information
Year Manufacturer / Company Equipment Serial # Weight Value
Loss Payee/ Lender Information
  Lender Name     Address     Account #     Loss Payee     Additional Insured  
Yes No Yes No
Yes No Yes No
Yes No Yes No
Blanket Small Tools (unscheduled equipment valued $1,000 or less). If yes Total value
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