Auto / equipment

VEHICLE/FIELD EQUIPMENT: ADD/DROP FORM
FAX OR E-MAIL TO BC ENVIRONMENTAL INSURANCE BROKERS
FAX: (916) 939-1085 E-MAIL: BCOFFICE@ENVIRONMENTALINSURANCE.COM PHONE: (916) 939-1080

DATE OF REQUEST :

- Month - Day Year

YOUR NAME:

COMPANY NAME:

PHONE NUMBER:

FAX NUMBER:

INSURANCE COMPANY:

TYPE OF POLICY:

EMAIL ADDRESS:

POLICY NUMBER:

VEHICLE INFORMATION:

ADD DROP

DATE ACQUIRED :

- Month - Day Year

FULL ADDRESS WHERE VEHICLE WILL BE GARAGED:

VEHICLE ID (VIN) NUMBER:

YEAR:

MAKE:

MODEL:

COLLISION COVERAGE NEEDED?

Yes No

IF YES, DEDUCTIBLE: $

Same as Policy

COMPREHENSIVE COVERAGE NEEDED?

Yes No

IF YES, DEDUCTIBLE: $

Same as Policy

IF YOU WANT COLLISION, WHAT IS THE VEHICLE'S VALUE?

FIELD EQUIPMENT INFORMATION:

ADD DROP

IS THE EQUIPMENT:

OWNED LEASED RENTED

DATE ACQUIRED:

- Month - Day Year

IF MORE THAN ONE ITEM, PLEASE ATTACH LIST SHOWING ITEMS AND VALUES

DESCRIPTION OF EQUIPMENT:

DOLLAR VALUE $

YEAR AND MAKE:

MODEL:

SERIAL #:

IF LEASED OR RENTED, LENGTH OF LEASE/RENTAL:

- Month - Day Year

TO

- Month - Day Year

(If rented/leased longer than 30 days, equipment must be added to 'Scheduled Equipment List'.)

PLEASE ISSUE CERTIFICATE:

ADDITIONAL INSURED LOSS PAYEE

NAME OF CERT. HOLDER:

ADDRESS:

CITY

STATE

ZIP

IF THE AUTO OR FIELD EQUIPMENT IS FINANCED OR LEASED, THE BANK OR LEASE COMPANY WILL WANT A 'LOSS PAYEE ENDORSEMENT'. PLEASE LIST

LOSS PAYEE NAME:

ADDRESS:

CITY

STATE

ZIP

LOAN NUMBER: