IMPORTANT NOTICE
1. This equipment insurance quote request applies only to the states of Oregon and Washington. Do not fill out this form if your equipment is not located and used in Oregon or Washington.

2. No insurance will be started by submitting this form. Coverage may be placed in force only after you decide to purchase it from us, and then after you complete the insurance application and pay the initial premium.

3. Submitting the following quote request constitutes your agreement with the above statements. We will contact you within two business days after we receive your request. If you have questions concerning this notice or about the following form, please call us at 503-620-0230 or 1-888-620-0230.

Equipment Insurance Quote Request
  1. Your First Name
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  2. Middle Initial
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  3. Last Name
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  4. Your business name or DBA
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  5. Phone Number
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  6. Fax Number
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  7. Email Address
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  8. Business Website, if any
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  9. Street Address
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  10. City
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  11. State
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  12. Zip Code
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  13. Location of equipment if different from above
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  14. Describe your business (What does it do?)
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  15. How many years in business?
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  16. Are you the owner of the equipment?
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  17. In the box below, describe the equipment as best you can. For specific high-value items, give year made, make, model, ID#, and value.
  18. Describe your equipment
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  19. Is equipment currently or previously insured?
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  20. If 'Yes', insurance company name
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  21. Expiration date of coverage
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  22. If coverage was canceled, explain why
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  23. Describe any claims or losses the last 5 years
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  24. In the following box, describe what security measures you take to prevent vandalism to or theft of your equipment
  25. Security Measures
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  26. Additional information or comments
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  27. Re-type the Security Field numbers in the box.
  28. Security Field
    Security Field The Security code you typed did not match. Please click "Refresh" and try again.
  29. To keep a copy of this form, please Print before Submitting
  30.   

 

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Questions?

If you have questions concerning this information, please call us at 503-620-0230, or come in.

Llámenos ya al 503-620-0230.