Mobile Equipment Identification : Joint Powers Insurance Authority

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Mobile Equipment Identification

Mobile equipment Identification fields marked with * are required and fields marked with ** are required only if adding mobile equipment (Add is chosen in Policy Change field). As an alternative, you may also download this form in an adobe document format, fill it out, and either fax it to (916)774-7040 or email it to the Member Services Department.

Mobile Equipment Information
* Policy Change
* District
** Date Aquired	('mm/dd/yyyy' format only)	Unit Number
* Equipment Year		* Manufacturer
* Model		* Description
* Equipment Serial Number		** Estimated Value
Please list all accessories below. Including, Buckets, Scrapers, etc.
Accessories
** Capacity of Equipment	(Cubic Yards, KW, GPM, CFM, etc.)
** Lease or Financed		** Permanently Mounted to Licensed Trailer
Contact Information
* First Name		* Last Name
* Email