Tools BSRO Enrollment

State of Operation

Please tell us what state you are in.
NOTE: This Program is not available in California.
Your State
We are sorry! This program is not available in California.

Please consult with your store manager for more information.
Employee Information

Please tell us about yourself and what store you work for.
First Name
Last Name
Employee ID
Your Email Address
Store Name
Store Phone Number
Format: (000) 000-0000.
Store Address
Street Address
City
State
Zip Code

Large Tools Information

Please tell us about your large tools.
Based on replacement cost to purchase the item NEW, are any of your tools individually worth $1,000 or more?
Please list all tools larger than $1,000 in value.
- Please include as much detail as possible.
- For item values, please enter the replacement cost to purchase the item NEW. (Must be at least $1,000.)
Add More Items?
Add More Items?
Please proceed to the next page.

Small Tools Information

Please tell us about your small tools.
What is the total replacement value of your smaller tools (valued at less than $1,000 each)?
Please do not include the value of any larger items listed on the preceding page.

Insurance Information
Total Tools Equation1
Less 3000 Equation1
Insurance Limit Equation 1
Weekly Payroll Equation 1
- BSRO already provides you with tools reimbursement up to $3,000 in value at no cost to you. This voluntary program will allow you to purchase insurance for the tools you own beyond the first $3,000 reimbursement provided by BSRO.
- The insurance carrier for this insurance program requires that your insurance limit be rounded up to the nearest $1,000 (see Your Insurance Limit below).
- If you decide to enroll in the program, the premium for this insurance will be deducted from your paycheck by BSRO on a weekly basis (see Weekly Payroll Deduction amount below).

Final Enrollment
Based on the above information, would you like ot enroll in the BSRO tool insurance program?
You have elected not to enroll in the Tools BSRO Voluntary Employee Tool Insurance Program. Therefore, you do not have coverage for your tools beyond the $3,000 reimbursement that is automatically provided to you by BSRO.
How many theft losses, if any, have you had in the last three (3) years?
Final Authorization
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Total Value of Your Tools	${Total_Tools_Equation1}
Less $3,000 Reimbursement Provided by BSRO	${Less_3000_Equation1}
Your Insurance Limit	${Insurance_Limit_Equation_1}
This is the amount of insurance you'll need to cover your tools (above the $3,000 limit provided to you already by BSRO).
Weekly Payroll Deduction	${Weekly_Payroll_Equation_1}
This is the amount of insurance premium that will be deducted from your paycheck by BSRO on a weekly basis. The insurance limit shown has been rounded up to the nearest $1,000 of your tools value (less $3,000 limit provided by BSRO).

Total Value of Your Tools	${Total_Tools_Equation1}
Because the total value of your tools is less than $3,000, additional insurance is not needed. BSRO already provides you with tools reimbursement up to $3,000 in value.

State of Operation