Fillable Automobile Physical Damage Insurance Commercial Vehicles Application Lloyds (Strickland Insurance Brokers)

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Automobile Physical Damage Insurance Commercial Vehicles Application Lloyds (Strickland Insurance Brokers)

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  • 172 other fields

Country of origin: US
File type: PDF

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LL-CA 08/12
Effective Date: From ________________ to ____________________
QUESTIONS OR STATEMENTS
1. Garaging Address if other than above:
2. Describe Business Operations:
3. What is the Radius of Operation?
4. Largest City entered in each state:
5. Exact type of Cargo Hauled:
6. Number of years in Business:
7. With the exception of Lienholders, are all vehicles owned solely by and registered to the applicant?
If no, explain:
Yes No
8. Name of Carrier of Liability and Property Damage Insurance:
9. Is vehicle(s) owner driven?
If drivers are employed, what are the hiring practices?
Yes No
10. Has Applicant had previous Fire, Theft and Collision Automobile Insurance cancelled?
If yes list
a) Prior Carrier:
b) Reason for cancellation:
Yes. No
11. If more than one vehicle is covered, what is the estimated maximum possible terminal loss?
12. Are any vehicles customized, altered, or have special equipment?
Explain or attach description:
Yes No
13. Will any of your equipment ever be loaned or rented to others?
If yes, with or without drivers? ________________
If without, what driver control or safety precautions are taken? ____________________________________
Yes No
14. Is equipment regularly inspected and services?
If yes, at what periods:
Yes No
TYPE OF OWNERSHIP OF BUSINESS: (PLEASE CHECK ONE)
INDIVIDUAL
PARTNERSHIP (MARRIED COUPLE)
PARTNERSHIP (ALL OTHER)
CORPORATION
Name of applicant
Producer Code: Phone:
DBA
Name:
Address:
Address:
City:
City:
State:
Zip Code:
State:
Zip Code:
Automobile Physical Damage Insurance
Commercial Vehicles Application
Lloyds of London
Phone # 888-495-4950
Fax # 888-997-9970
P.O. Box 8010
Goldsboro, NC 27533-8010
LL-CA 08/12
15. D
r
ive
r
In
fo
r
m
a
t
io
n
Driver
#
Name
Date of Birth
Driver License
Number & State
Description of violations and Accidents (Past 3 years)
16. P
r
evio
u
s
In
su
r
a
n
ce and
L
oss
E
x
p
e
r
ie
n
ce
Policy Period
Insurance Carrier
Policy #
Number
of
Accidents
Total
Amount
Paid Fire
Total
amount Paid
Theft
Total
amount Paid
Collision
Any other
Physical
loss
Open
Claims
From To
From To
From To
From To
17. Desc
r
i
p
t
io
n
of Ve
h
icle
:
(S
p
ecify
T
r
u
c
k
,
T
r
a
c
t
o
r
,
T
r
a
ile
r
, Se
m
i)
Veh #
Year
Make/Model Body Type Loaded
GVW/Seating
Capacity
Vehicle Identification Number Stated
Amount
Deductible
18. Loss
P
a
yee
VEH # NAME ADDRESS CITY, STATE ZIP
APPLICANT
PLEASE
RE
AD
This application, being submitted through Strickland Insurance Brokers, Inc., shall not be binding on the Underwriters unless and until a contract of insurance shall
be issued and delivered in accordance herewith and then only as of the commencement date of said Insurance and in accordance with all terms thereof and the said
Applicant hereby covenants and agrees to and with the Underwriters that the foregoing statements and answers are just, full and true exposition of all the facts and
circumstances with regard to the risk to be insured, insofar as the same are known to the Applicant, and the same are hereby made the basis and condition of the
Insurance.
APPLICANT’S
SIGNATURE DATE TIME
PRODUCER’S SIGN
A
T
U
RE
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Automobile Physical Damage Insurance Commercial Vehicles Application Lloyds (Strickland Insurance Brokers)

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Completed 17 July 2021

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