Equipment Insurance Serivces

Already a Client
Signup Now

Business Information
Company:		Date:	3/10/2010
Primary Contact:		Title:
Email Address:
Address:		Phone:
Address:		Fax:
City:		Start Date:
State:	Zip:	Fed Tax No.
Business Type:	Sole Proprietorship Partnership Corporation Other:
Business Ownership and Credit Information
Principal Name:		Social Security:
Email Address:		% Ownership:
Home Address:
City:		Home Phone:
State:	Zip:	Alt Phone:
How Long at current Address:
Bank Name:
Bank Address:		Phone:
City:		Fax:
State:	Zip:
Type of Account:	Account Number
Savings
Checking
Other
Insurance/Business References
Insurance Company:
Contact:		Email:
Address:
City:		Phone:
State:	Zip:	Fax:
Policy Information:		Claims History:

Business Reference
Company Name:		Type of Account:
Contact:		Email:
Address:
City:		Phone:
State:	Zip:	Fax:

Business Reference
Company Name:		Type of Account:
Contact Name:		Email:
Address:
City:		Phone:
State:	Zip:	Fax:
Agreement
By submitting this Application, I understand and agree on behalf of the applicant, as its authorized representative, that Equipment Insurance Services, LLC is (1) entitled to rely on the above information in the evaluation of this Application, and (2) authorized to conduct a credit investigation of the applicant, including but not limited to contacts with credit reporting agencies and persons or entities identified in this Application. The information contained in this Application is true and correct. If accepted into the Lessor Insurance Program, the applicant agrees to be bound by the Lessor Insurance Program Agreement.
Submitted By:		Title: