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(Fields marked * are required.)
(Select at least one area of operations. You may select more than one area.)
Please note that we do not offer coverage in the United States.
Claims Experience: Describe all claims in the last five years (include all relevant details, such as dates)
If "Other", amount ($):
The following form allows you to enter in all relevant truck, equipment, and tools that are to be included as part of your insurance coverage. For each additional item to be added, click the "Add another row" button at the end of the form to add more space.
Adding and removing rows is unavailable to clients with Javascript disabled.
YOU CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND ACCURATE AND APPLY FOR A CONTRACT OF INSURANCE BASED UPON THE TRUTH OF THE STATEMENTS.
YOU ARE IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE AGREEMENT.