Crane Operators & Rental Application Name Insured(s): (Please list all applicable named insured to be covered to include buildings owned by principals, partnerships, DBAs, etc. if insurance required) Contact Name*Title*Email* Phone Number*Fax NumberWebsite Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy Period From Policy Period To Current Carrier*Business Inception Date* Federal Tax ID Number*Business Type*CorporationPartnershipProprietorshipOperationsPlease provide estimated gross receipts and payroll along with breakdown %:A. Total OperationsRECEIPTS:$Payroll:$CranesCranesType & Make DescriptionYearCurrent ValueReplacement CostMaximum Reach & Lift CapacitySerial Number CRANE OPERATORS DRIVING INFORMATIONCranesDriver NameBirthdateDrivers License #State Of LicenseHeaviest Crane Driver OperatesYears Experience Operating Cranes Estimated Losses for Past 5 Years: $*Date* Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.
