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Inland Marine Equipment

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General Information
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BIA Chamber of Commerce
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Named Insured: *
 Contractor's License #:
Owner's Name: *
 Contact's Name: *
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 Preferred method of contact: *
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Address Information
Mailing Address
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City: *
State: *
Zip: *
 
Premise Address
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Business Entity: *
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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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