Inland Marine Please complete all required fieldsYour InformationFirst Name *Last Name Email Address *Telephone/Cell Number Facsimile Number Address Apt, Ste etc. City State Zip Coverage InformationCurrent Carrier Current Premium Policy Period Office Contents $ Computer Systems – Data & Media $ Computer Systems-Equipment $ Miscellaneous Hand Tools & Small Equipment $ Valued under $1,500Scheduled Equipment /Tools VALUED OVER $1500Amount Serial # Description Amount Serial # Description Amount Serial # Description Amount Serial # Description Amount Serial # Description Amount Serial # Description Amount Serial # Description Amount Serial # Description Amount Serial # Description Installation Floater $ Rented / Leased Equipment $ (from others )PLEASE READ THIS APPLICATION CONTAINS THE INFORMATION NEEDED TO START YOUR POLICY. IN SOME CASES IT MAY BE NECESSARY TO TRANSFER THIS INFORMATION TO ONE OR MORE CARRIER SPECIFIC FORMS. IF THAT IS NECESSARY WE WILL COMPLETE THEM FOR YOU AND SIGN ON YOUR BEHALF WITH THE INFORMATION FROM THIS APPLICATION. CLIENT AGREES TO INDEMNIFY AND HOLD HARMLESS TOP CONTRACTORS INSURANCE SERVICES INC., ANY OF ITS EMPLOYEES AND AGENTS, ALONG WITH ANY OF ITS AFFILIATED COMPANIES FROM AND AGAINST ANY AND ALL CLAIMS ARISING OUT OF OR RELATION TO ANY ALLEGED FAILURE TO ACT ON THE PART OF THE CLIENT WHICH RESULTS IN ANY CLAIM, DEMAND, ACTION, OR CAUSE OF ACTION AGAINST TOP CONTRACTORS INSURANCE SERVICES INC., OR ITS AFFILIATED COMPANIES.Name *Date *FEIN *Application Information THIS APPLICATION CONTAINS THE INFORMATION NEEDED TO START YOUR POLICY. IN SOME CASES IT MAY BE NECESSARY TO TRANSFER THIS INFORMATION TO ONE OR MORE CARRIER SPECIFIC FORMS. IF THAT IS NECESSARY WE WILL COMPLETE THEM FOR YOU AND SIGN ON YOUR BEHALF WITH THE INFORMATION FROM THIS APPLICATION. CLIENT AGREES TO INDEMNIFY AND HOLD HARMLESS TOP CONTRACTORS INSURANCE, ANY OF ITS EMPLOYEES AND AGENTS, ALONG WITH ANY OF ITS AFFILIATED COMPANIES FROM AND AGAINST ANY AND ALL CLAIMS ARISING OUT OF OR RELATION TO ANY ALLEGED FAILURE TO ACT ON THE PART OF THE CLIENT WHICH RESULTS IN ANY CLAIM, DEMAND, ACTION, OR CAUSE OF ACTION AGAINST TOP CONTRACTORS INSURANCE SERVICES INC, OR ITS AFFILIATED COMPANIES. VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank
