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Insurance
Floater Insurance Add / Delete Form
(Equipment Floater)
      You may download the Word document and fill it out, then fax to:

Insurance Department
FAX: 935-9795
Attn: Jane Nothaker

or fill out the required information in the boxes below and click "submit" to transmit electronically to the Insurance Department.

A copy of the completed Add/Delete form will be e-mailed to you as confirmation of receipt

Dept. Name:
Dept. Number:
Dept. Representative:
Extension Number:
Box Number:
 
Add or Delete: Add this Item Delete this Item
Effective Date:
Description:
Manufacturer:
Model #:
Serial #:
Purchase Cost:
Purchase Date:
Building Number:
Campus: Danforth Campus Medical Campus


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