If the evidence of insurance is related to a BUILDING
you or your company owns or leases, please click here.

Information regarding the Building:

Year Make Model
Loan Number (if known)

Information regarding the Lending company or Bank:

Name of Lender
Attention
Mailing Address
City
	State   Zip -

Is this a new lender on this vehicle?	YES NO
If you checked "NO", does this represent just    an address change for the lender?	YES NO
If you checked "YES", should we    remove the previous lender?	YES NO
Do you want a copy of this evidence    sent to you as well as the lender?	YES NO

Do you you want the evidence FAXED or MAILED to the lender?

If you answered "FAXED", to what fax
number shall the evidence be sent:   - -

If the evidence of insurance is related to a piece of EQUIPMENT (computers,
copy machines, contractor's equipment, etc.), please click here.

Information regarding the piece(s) of equipment:

Year
Manufacturer
Description
Model
Serial Number

Click HERE if there are other pieces of equipment to which
this lending company or bank is to be added as a loss payee.

DISCLAIMER:

COVERAGE CANNOT BE BOUND ON ANY EQUIPMENT BY USE OF THIS SYSTEM. IF YOU HAVE NEW PIECES TO BE ADDED TO YOUR INSURANCE POLICY OR IF YOU WISH TO MAKE ANY CHANGES WHATSOEVER, YOU CAN COMMUNICATE YOUR WISHES TO US ELECTRONICALLY, BUT COVERAGE CANNOT BE CONSIDERED BOUND OR MODIFIED UNTIL YOU HAVE RECEIVED VERBAL, WRITTEN, OR ELECTRONIC CONFIRMATION OF SUCH ADDITION OR CHANGE.