(changes will be effective upon confirmation by a King & Neel representative)


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(* means required)

 

* Your Business Name

   

* Your Name

      * Phone 

 * Email Address

Fax Number

 * Effective Date of the Change

   

 

Bought a piece of equipment
Got rid of a piece of equipment vehicle
Change to existing equipment
Other (specify below) 

 


 

 

Description of the equipment to change:

* Model Year  * Make/Model 

Type  * Serial Number

Insure for $

       Replacement Cost   Actual Cash Value

 

Description of any parties with Additional Interests:

Is the equipment financed?  YES  NO

Is the equipment leased?  YES  NO
If yes, full name and address of the Loss Payee:
(a certificate of insurance will be issued)
If yes, full name and address of the Lessor
(a certificate of insurance will be issued):

 

 

OTHER COMMENTS OR REMARKS?

 

If you would like a copy, please PRINT before hitting "submit".  Thank you!