Fillable Leased & Financed Equipment Insurance Verification Form printable pdf download

CONTRACT NO.

Leased & Financed Equipment Insurance Verification Form

Lessee Company Name

Lessee Company Contact

Equipment Description

Lessee Phone

Equipment Value*

*(Insured Amount)



Yes, I would like to be enrolled in the CLI Leasing

No, I will provide evidence of my own insurance that meets

Corp. Protection Program as described below.

the requirements of my lease agreement.

Agent Name: ___________________________

Monthly Insurance Charge: $____________

Agent Phone: ___________________________

Deductible $____________

Lessee/Borrower Initials ______________________ Date ____________________

CLI Leasing Corp. Equipment Coverage Program

Our policy provides FULL REPLACEMENT coverage for several important types of loss for which many business insurance

policies provide only ACTUAL CASH VALUE coverage, or EXCLUDE altogether. Our policy protects against losses due to:

Burglary, Theft & Robbery

Vandalism

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Fire

Wind, Hurricane & Tornado

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Lightning & Power Surge

Employee Theft

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Accidental Damage

Flood and Water

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Valuation & Settlement of Covered Losses

If there is a loss on the equipment covered under our policy, simply call 866-223-6385 to provide a statement about the loss to

Premier Lease & Loan Services, our insurance manager. The insurance company settles covered losses in the event of damage

or loss due to a covered cause of loss, using one of the following methods:

Repair of the covered equipment, when repairable; or Replacement of the covered equipment, when the equipment

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was new at the time of the lease or finance contract and is not repairable and is replaced under the same contract.

When the equipment is replaced, the loss is valued on a full “replacement cost” basis; or

Payment to us for the Stipulated Loss Value of the covered equipment at the time of loss, if the covered equipment is

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totally destroyed or lost and we choose not to replace it under your contract; or if the covered equipment was used

equipment at the time of the lease or finance contract.

Key Losses Not Protected; Exclusions

We do not cover loss caused by or resulting from:

Loss of market, business interruption, or any other consequential or indirect loss.

Mechanical breakdown and maintenance, wear and tear, inherent vice, latent defect.

Earthquake and earth movement.

Rust, corrosion, marring, and scratching; wet or dry rot, freezing, heating.

Shortage of equipment that is discovered upon taking inventory.

Abandonment.

Dishonest or criminal acts (including misappropriation, conversion, and skip) by shareholders, directors, owners, or

partners.

War, governmental action, nuclear reaction, radiation, or radioactive contamination.

Contaminants or pollutants.

(Additional perils not covered and definitions are described in the policy.)

This document is not an insurance policy. This document is designed to explain the terms and conditions of the Leased Equipment Insurance Policy issued to the Lessor Premier Lease & Loan Services.

This document is a condensed version of the Policy, and is subject to all terms and conditions of the Policy. It DOES NOT include all the limitations and terms of the Policy. You can look at the Policy at

the Lessor’s address shown on your lease agreement. The Lessor is the only insured under the Policy.