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COMPETITION VEHICLE/MARINE INSURANCE

· 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)


APPLICATION

Insured Name :
Address :
Occupation :
Contact Person :
Contact Information :
Location (if different) :
Effective Date :

INVENTORY SCHEDULE

#Competition VehicleList Value of VehicleList Vehicle Name
or Identifying Marks
Provide Replacement Value
1. $$
2. $$
3. $$
4. $$
5. $$
#Equipment (Tools, Spare Parts, etc.)
- Description of all items over $2,500
List Value of Equipment
– Over $2,500
List Serial Numbers
or Identifying Marks
Provide Replacement Value
1. $$
2. $$
3. $$
4. $$
5. $$
Provide Total Value of all Unscheduled Equipment: (Not Listed Above)$
#Trailers - DescriptionList Value of TrailerList 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


Type the code shown

Submit




UNDERWRITERS

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or a part of an individual's income is derived from any public assistance program. (Not all prohibited bases apply to all programs.)
Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at 202-720-2600 (voice and TDD).
To file a complaint of discrimination write to:
USDA
Director, Office of Civil Rights
1400 Independence Avenue, S.W.
Washington, D.C. 20250-9410
or call 800-795-3272 (voice)
or 202-720-6382 (TDD).

USDA is an equal opportunity provider and employer.