Owens Insurance Agency, Inc. PO Drawer 1375 Clinton MS 39060 PH: 601-924-9311 FAX: 601-924-0549 Agricultural and Commercial Equipment Physical Damage Insurance Application/Binder Applicant Producer Name Name Name Name Addr Addr Addr Addr Phone Phone Email Email Nature of Business/Description of Use General Information – Explain all “yes” responses 1. Is equipment being leased or rented to others by the insured? 2. Is the equipment being used in a logging, forestry or custom harvesting operation? 3. ATV only - Is anyone under the age of 16 operating the unit? 4. Has any coverage been declined, cancelled or non-renewed for any reason in the past 3 years? Effective Date Expiration Date Total Policy Limit Deductible (per listed item) Binder Number
Transcript
Owens Insurance Agency, Inc. PO Drawer 1375
Clinton MS 39060 PH: 601-924-9311 FAX: 601-924-0549
Agricultural and Commercial Equipment Physical Damage Insurance Application/Binder
Applicant Producer Name Name Name Name Addr Addr Addr Addr Phone Phone Email Email Nature of Business/Description of Use
General Information – Explain all “yes” responses
1. Is equipment being leased or rented to others by the insured?
2. Is the equipment being used in a logging, forestry or custom harvesting operation?
3. ATV only - Is anyone under the age of 16 operating the unit?
4. Has any coverage been declined, cancelled or non-renewed for any reason in the past 3 years?
Effective Date Expiration Date Total Policy Limit Deductible (per listed item)
Binder Number
Debby
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COVERAGE INFORMATION
Debby
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Debby
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Premium
Debby
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Debby
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Debby
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Policy Fee
Debby
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Debby
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Debby
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Total Due
Debby
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Debby
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I hereby make application for the insurance coverage described in the below schedule. The option has been extended to me to purchase the insurance from any Company or Agent of my choice or to assign a policy which I possess and I freely choose the coverage herein applied for. I also agree there is no existing damage to the equipment listed below. I acknowledge a policy fee has been charged. The full amount will be returned in the event of a flat cancellation otherwise the fee will be used to offset short term cancellation and is fully earned. WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of insurance fraud.
