SPECIALTY PROPERTY- LOGGING APPLICATION

Applicant’s Name (Legal and Operating):	Broker:	Policy Period: to (12:01 AM)
Applicant’s Address:	Location of Insured’s Property:
Principal Name:	How Long in Business:
Loss and Policy History
Previous claims in the past 5 years? Yes, No Describe:
Previous Insurer:	Policy #:
Has any insurer cancelled, declined or refused to renew Commercial Insurance in the past 5 years? Yes, No
Supporting Business: Policy #:	Company:
Schedule
Item #	Model Year	Trade Name	Model	Body Type	Serial #	List Price New	P. Price
Coverages
Item #	Coverages Cont Equip- LLDS-1128	Named Perils	(Ded 5%) Min $2500	Co. Ins %	Amount Ins.	Rate	Premium
Yes	Yes	No. Co.
Yes	Yes	No. Co.
Yes	Yes	No. Co.
Yes	Yes	No. Co.
Please describe operations: Equipment must be protected by at least one 20 lb ABC fire extinguisher. Policy will be subject to warranty. Where will applicant be operating the above described equipment (specific location)? Address: How long has the applicant been in the logging/lumbering business? Where is equipment stored when not in use? Will applicants’ equipment be rented or leased? Rented Leased How often is equipment serviced & by whom? Please confirm amount of lien on each piece of equipment. Operators (Name and Experience):
M.R.P: $	Total Premium: $

Signed By:	Date: