Add or Remove Auto/Property/Mobile Equipment Add or Remove Auto/Property/Mobile Equipment 1Member Information2Property/Auto/Mobile Equip Info3Submission Type of Request * RequiredAdd AutoRemove AutoAdd PropertyRemove PropertyAdd Mobile EquipmentRemove Mobile EquipmentEntity Name * Required Contact Name * Required First Last Phone * RequiredEmail * Required Preferred Methof of Contact * Required Phone Email Effective Date of Change * Required MM slash DD slash YYYY Year * Required Make * Required Model * Required Serial # * Required Value * Required Deductible * RequiredChoose your desired deductible$5,000$10,000$25,000$50,000$75,000$100,000VIN * Required Average Retail Value * Required Include Comp. & Collision? * Required Yes No Comp. & Collision Deductible * Required $500 $750 $1000 Property Name * Required Physical Address * Required 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 * Required Construction Type * Required 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? * Required Yes No Year Built * Required Square Footage * Required Number of Floors * Required Condition * Required New Good Fair Poor Deductible $5,000 $10,000 $25,000 $50,000 $75,000 $100,000 Replacement Value * RequiredBuilding must be scheduled at replacement value.Contents Value * RequiredContents 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 * RequiredElectronic Data Processing. All computer-related equipment, including software, owned or leased by the participant. Schedule at replacement cost. Fine Art Value * RequiredPaintings, tapestries, art glass windows, valuable rugs, statuary, antique furniture, etc., whether inside or outside the building. Schedule at replacement cost. Garaged Vehicle Value * RequiredTotal 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 * RequiredLoss 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 * Required First Last Δ
