<p> Chubb Group of Insurance Companies Application Machinery Breakdown Insurance CHUBB Request for Quotation for Homeowners</p><p>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.):</p><p>LIMITS & COVERAGES</p><p>Property Damage: $500,000 (min) Deductible: $______($1,000 minimum deductible) Extra Expense : (provided automatically) $100,000 LOCATION INFORMATION</p><p>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)</p><p>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) </p><p>Current Masterpiece Yes? No? Current Property $ Client? Deductible? Additional Comments or Requests: </p>