Balloon Rider Form
Policyholder Information
Name of Policyholder
First Name
Last Name
Policy Number
Date
-
Month
-
Day
Year
Date
Balloon Information
Balloon Make and Model
Balloon Registration/Serial Number
Year of Manufacture
Coverage Details
Liability Coverage
Coverage for bodily injury and property damage liability arising from the use of the balloon.
Coverage Limits
Bodily Injury Liability Limit
per person
per accident
Property Damage Liability Limit
per accident
Physical Damage Coverage
Coverage for damage to the insured balloon, including collision and comprehensive coverage.
Coverage Deductible (If Applicable)
Additional Endorsements/Custom Coverage
Coverage Limit (If Applicable)
Rider Effective Date
-
Month
-
Day
Year
Date
Expiration Date
-
Month
-
Day
Year
Date
Total Premium for Balloon Coverage
Payment Method
Bill Me
Credit Card
Electronic Funds Transfer
Authorization
I hereby request the addition of the above-specified balloon coverage to my insurance policy with [Insurance Company Name]. I understand that the coverage and terms are subject to the policy provisions, conditions, and exclusions.
Date
-
Month
-
Day
Year
Date
Policyholder's Signature
Submit
Should be Empty: