Have You Had Any Machinery Breakdown Losses in Previous 5 Years? Yes No

Chubb Group of Insurance Companies Application Machinery Breakdown Insurance CHUBB Request for Quotation for Homeowners

Producer: Date of Request: Application Completed By: Quote Needed By: Name of Account: Mailing Inception Date: Address: Expiration Date: Describe any large or unusual machinery or equipment exposures (heating, cooling, power generation, etc.):

LIMITS & COVERAGES

Property Damage: $500,000 (min) Deductible: $______($1,000 minimum deductible) Extra Expense : (provided automatically) $100,000 LOCATION INFORMATION

Address, City, State Building Contents TOTAL Annual Loss of Value Replacement Rental Income (if Value applicable) 1. 2. 3. 4. 5. (Attach additional sheet if more than five locations- DO NOT include fine arts or jewelry in values)

LOSS HISTORY Have you had any machinery breakdown losses in previous 5 years? Yes No If yes, please explain (include description of occurrence, machinery involved and amount of loss/claim)

Current Masterpiece Yes? No? Current Property $ Client? Deductible? Additional Comments or Requests: