Add or Remove Auto/Property/Mobile Equipment Add or Remove Auto/Property/Mobile Equipment 1Member Information2Property/Auto/Mobile Equip Info3Submission Type of Request*Add AutoRemove AutoAdd PropertyRemove PropertyAdd Mobile EquipmentRemove Mobile EquipmentEntity Name*Contact Name* First Last Phone*Email* Preferred Methof of Contact* Phone Email Effective Date of Change* MM slash DD slash YYYY Year*Make*Model*Serial #*Value*Deductible*Choose your desired deductible$5,000$10,000$25,000$50,000$75,000$100,000VIN*Average Retail Value*Include Comp. & Collision?* Yes No Comp. & Collision Deductible* $500 $750 $1000 Property Name*Physical Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code GPS Coordinates*Construction Type* Non-Combustible Steel Frame Concrete Block Fire Resistive All Steel – Including metal frame construction Masonry Construction/Wood Roof All Combustible/Wood Frame Mixed Non-Combustible/Combustible Fire Protection Sprinklers?* Yes No Year Built*Square Footage*Number of Floors*Condition* New Good Fair Poor Deductible $5,000 $10,000 $25,000 $50,000 $75,000 $100,000 Replacement Value*Building must be scheduled at replacement value.Contents Value*Contents include any movable personal property, office equipment, and furniture. Schedule at replacement cost. Do not include EDP, Fine Arts, Mobile Equipment, or Garaged Vehicles. EDP Value*Electronic Data Processing. All computer-related equipment, including software, owned or leased by the participant. Schedule at replacement cost. Fine Art Value*Paintings, tapestries, art glass windows, valuable rugs, statuary, antique furniture, etc., whether inside or outside the building. Schedule at replacement cost. Garaged Vehicle Value*Total average of actual cash value automobile(s) housed within the Participant’s own facility. Do not include Mobile Equipment. De not include any vehicle listed for comprehensive & collision coverage. Business Interruption Value*Loss of earnings resulting from interruption of business operations during the time required to rebuild or repair property damaged or destroyed by an insured peril; annual earnings value. Printed Name of Person Submitting Form* First Last NameThis field is for validation purposes and should be left unchanged. Δ
