- Coverage provided on a replacement cost basis (no depreciation)

- Coverage available for tools and parts as well as specialty vehicle

- Liability coverage is available

- Trailers can be included instead of being put on the auto policy

- Coverage is written with a A+XV rated carrier

- Coverage is written on an admitted basis (No surplus lines taxes or fees)

- Auto policies available for Semis, Toters, and Trailers
Insured Name :
Address :
Occupation :
Contact Person :
Contact Information :
Location (if different) :
Effective Date :

INVENTORY SCHEDULE

#Competition VehicleList Vehicle Name
or Identifying Marks
Provide Replacement Value
($)
1.
2.
3.
4.
5.
#Equipment (Tools, Spare Parts, etc.)
- Description of all items over $2,500
List Serial Numbers
or Identifying Marks
Provide Replacement Value
($)
1.
2.
3.
4.
5.
#Trailers - DescriptionList Serial Numbers
or Identifying Marks
Provide Replacement Value
($)
1.
2.
3.
4.
5.

Desired Deductibles

Deductible Amount:$1,000$2,500$5,000$10,000Other
Vehicle / Chassis / Trailers
All Other Items

Claims Experience

Claim Description:Amount Paid:

Additional Comments



How did you hear about us ?



















*Please provide past 5 year hard copy loss runs and description of any individual claim or reserve in excess of $10,000
*Completion of this form does not bind coverage


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