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Phone: 847-367-0900
Videography/Photography
Self Storage
MCA-I
Business Insurance

Equipment/Liability Insurance Application

 

Equipment/Liability Insurance Application
   
Business Name *      Legal Entity *      
Mailing Address *    City *      State *      Zip      
Contact Name      Phone *    
Fax *      Email *      Web Site      
Business Location (If different than above) - Note: If more than one permanent location, please schedule on separate sheet.
   
Primary Business Location is *      Construction *      
Do You have Central Station Alarm *      Year Built *      
Sprinklered? *      # Floors In Building *     Square Footage of Studio *      
If Building Over 30 Years Old, when were electrical, roof, heating system, and plumbing last updated? 
   
What is the value of Business Personal Property owned by the applicant.*  
Including but not limited to: cameras, acessories, editing equipment, furniture, and fixtures etal.    (BPP)
Estimated Replacement Value *
Value of that portion of amount shown for question #4 that leaves your premises.      (Off Premises)
Estimated Annual Sales *      
Note Specific events/jobs you videotape/photograph. (Besides Weddings)
   
Number of Photographers *     Number of Videographers *  
List details and amounts paid to your business for any property or liablity claims in the last 3 years. If none, please indicate.
      
Do you currently carry:  
Equipment Insurance *      General Liability Insurance *    Errors and Omissions Insurance *      
  If Yes: Name of Insurance Carrier      Expiration Date      
Has any company refused or cancelled your insurance? *      If yes, please list details below
     
Do you have any Aerial Activities *  
(including remote control and drone usage - companies engage in this tyoe of work not eligible for coverage)
   
Any Underwater Activities? *  
If Coastal, Distance From Beach      
Years In Business *      
Do you Rent your equipment to others?*      
Are you in any way involved in Television Production? *   If yes, list details below.
       

Wm. F. Buell, Inc.
621 E Park Ave.
Libertyville, IL 60058-2904

Fax: 847-367-7549
Should you have any questions, please call:

1-800-842-8355

ANY PERSON KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING FALSE INFORMATION
FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT, MATERIAL
THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME.

Applicant Name *      Title *     Date *     
                    
Located in Libertyville, IL . We also serve the Chicago, Los Angeles and New York areas. - Licensed in Alabama, Arizona, California, Colorado, Connecticut, Florida, Georgia, Iowa, Illinois, Indiana, Maryland, Michigan, New Jersey, New York, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia and Wisconsin