WSIB Insurance Agency, LLC

Applicant Information >

Storage Building Information >

Frame Construction?
(Check all that apply)

Steel

Wood

Concrete

Roof Construction?
(Check all that apply)

Shingles

Steel

Number of doors:

Do all doors lock?

Yes No

Number of windows:

Are the windows barred?

Yes No

Operating sprinkler system?

Yes No

Flammables or chemicals
stored in this garage?

Yes No

Fire extinguisher available?

Yes No

Installed alarm system?

Yes No

Alarm system in
working order?

Yes No

Do you store covered items
outside while at your shop?

Yes No

Is the outside yard adjacent to
the shop secured?

Yes No

Property Information >

Is vehicle kept in locked
storage?

Yes No

Will vehicles ever be loaned or
rented to others?

Yes No

If yes, explain:

Are all trailers enclosed?

Yes No

Is all equipment laid up and in
storage for more than four
months a year?

Yes No

If yes, how long?

Scheduled Property
Deductible:

$1,000

$2,500

$5,000

$7,500

$10,000

$15,000

List of Scheduled Property
(INCLUDE COMPETITION
VEHICLES, PARTS, TOOLS,
EQUIPMENT, ETC. TO BE
INSURED UNDER THIS
POLICY)

Scheduled Property	Price Includes Engine?	Insured Value (Stated Amount)
	Yes No	$
	Yes No	$
	Yes No	$
	Yes No	$
	Yes No	$
	Yes No	$
	Yes No	$
	Yes No	$
	Yes No	$

Misc. Equipment and Spare
Parts Deductible:
(Check all that apply)

$1,000

$2,500

$5,000

$7,500

$10,000

$15,000

List of Misc. Equipment, Tools,
and Spare Parts (LIST ALL
ITEMS OVER $2,500)

Misc. Equipment, Tools, and Spare Parts	Insured Value (Stated Amount)
	$
	$
	$
	$
	$
	$
	$
	$
	$

Trailers Deductible:
(Check all that apply)

$1,000

$2,500

$5,000

List of Trailers

Trailers	Insured Value (Stated Amount)
	$
	$
	$
	$
	$
	$
	$
	$
	$

Aggregate Limit? - Maximum
amount of payment in any one:

DISCLAIMER
Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime in some jurisdictions and subjects such person to criminal and civil penalties in some jurisdictions, including but not limited to fines, denial of insurance benefits, civil damages, criminal prosecution and confinement in state prison.

By completing this application, and in using the SUBMIT button, you are applying for insurance from WSIB only for the coverage specified in the application. Completion of the application in no way binds WSIB to provide insurance for either coverage requested or for coverages not requested on such application.