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INSURANCE FACT SHEET <br /> VALUE PRICE : <br /> MUNICIPALITY . Tnd ;u,i R :yer eauo :w F18flalcL <br /> CONTACT : 6eiti 3Qf'Qtan , fk:!5kk Mflnaevr PHONE : 072) 2, 2b - 12.41 <br /> EQUIPMENT DESCRIPTION : <br /> Pursuant to Section 13 of the Equipment Lease- Purchase Agreement dated as of <br /> , Lessee is obligated to provide insurance coverage naming CitiCapital Commercial <br /> Corporation as Loss Payee and Additional Insured . Please complete this form and return it with your <br /> documentation package and contact your insurance agent to forward a Certificate of insurance showing <br /> coverage . If you are self insured , please note as such below . <br /> PARENT INSURANCE COMPANY : <br /> ADDRESS : <br /> CITY : STATE : ZIP : <br /> PHONE : <br /> UNDERWRITER/AGENT COMPANY : <br /> ADDRESS : <br /> CITY : STATE : ZIP : <br /> CONTACT : PHONE : <br /> POLICY NO : EXPIRATION DATE : <br /> PUBLIC LIABILITY AMOUNT : DEDUCTIBLE : <br /> PHYSICAL DAMAGE <br /> AMOUNTS : COMPREHENSIVE : DEDUCTIBLE : <br /> PHYSICAL DAMAGE <br /> AMOUNTS : COLLISION : DEDUCTIBLE : <br /> OTHER COVERAGE : AMOUNTS : DEDUCTIBLE : <br /> OTHER COVERAGE : AMOUNTS : DEDUCTIBLE : <br /> INDICATE IF SELF-INSURED , OR IF POLICY IS CONTINUOUS : <br /> SELF- INSURED : ✓ YES NO <br /> LIABILITY: I PHYSICAL DAMAGE : OTHER : ALL : <br /> CONTINUOUS UNTIL END OF LEASE/ PURCHASE AGREEMENT : YES : �_ NO : <br />