TechAdvantage® Equipment Breakdown Quotation Request

NS, NB, PE, and NL

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Insured:

Date:

Mailing Address:

Contact Name:

Contact Phone no.:

Address of location:

Occupancy:

P.D. Values ($): enter dollar amount

Building ($): enter dollar amount

Equipment ($): enter dollar amount

Office ($): enter dollar amount

EDP ($): enter dollar amount

Stock ($): enter dollar amount

Tenant Improvements ($): enter dollar amount

Other ($): enter dollar amount

B.I. values: enter dollar amount

If Yes, date of loss:

Object:

Amount paid: enter dollar amount

Existing broker:

Existing Equipment Breakdown Carrier:

Existing Property Carrier:

Property damage: limit of liability enter dollar amount

Property damage: Deductible/Waiting period

Business interruption: Limit of liability

Business interruption: Deductible/Waiting period

Loss of profits: Limit of liability

Loss of profits: Deductible/Waiting period

Rent/rental value: Limit of liability

Rent/rental value: Deductible/Waiting period

Gross earnings: Limit of liability

Gross earnings: Deductible/Waiting period

Actual loss sustained: Limit of liability

Actual loss sustained: Deductible/Waiting period

Other: Limit of liability

Other: Deductible/Waiting period

Extra expense: Limit of liability

Extra Expense: Deductible/Waiting period

Spoilage: Limit of liability

Spoilage: Deductible/Waiting period

Product stored:

Automatic coverage:

By-Laws, Demolition and Increased Cost of Construction:

Errors and Omissions:

Hazardous Substance:

Water Damage:

Ammonia Contamination:

Professional Fees:

Expediting Expense:

Brands and Labels:

Public Relations:

Green Coverage:

Data Restoration:

Contingent Business Interruption**:

Off Premises Transportable Objects:

Service Interruption, includes Cloud Coverage**:

Civil Authority or Denial of Access:

Existing Policy No:

Anniversary Date:

Date Quotation Required:

Name:

City:

Contact person:

Phone no.:

Fax no.:

E-mail: *

Additional Information:

Submit

Thank you for your request. A representative from HSB Canada will contact you within 24 hours.

TechAdvantage® Equipment Breakdown Quotation Request

NS, NB, PE, and NL

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