Fillable Automobile Physical Damage Insurance Private Passenger Vehicles Application (Strickland Insurance Brokers)

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Automobile Physical Damage Insurance Private Passenger Vehicles Application (Strickland Insurance Brokers)

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The Automobile Physical Damage Insurance Private Passenger Vehicles Application (Strickland Insurance Brokers) form is 2 pages long and contains:

  • 2 signatures
  • 30 check-boxes
  • 228 other fields

Country of origin: US
File type: PDF

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LL-PP 02/13
QU
ESTIONS OR STATEMENTS
1. Garaging Address if other than above:
2. What is the regular Radius of Operation?
3. Use of the vehicle :
4. Has applicant had previous private passenger insurance that has been cancelled?
If yes, please provide detail:
Yes No
5. Are any protective appliances installed on the vehicle?
If yes please provide detail
6. Is there any special Equipment permanently installed on the vehicle?
If yes please provide detail:
Value of the Equipment included in stated amount
Yes No
7. Has the vehicle been altered, modified or changed in any way?
If yes, give detail
Yes No
8. Is primary Insured currently Employed? Occupation : Yes No
9 . Driver Information
10. Description of Vehicle:
Veh#
Year
Make
Model
Vehicle Identification Number
Stated Amount
Deductible
Sports Car
Four Wheel Drive
Yes. No Yes. No
Yes. No Yes. No
Yes. No Yes. No
Yes. No Yes. No
Yes. No Yes. No
TYPE OF OWNERSHIP : (PLEASE CHECK ONE)
INDIVIDUAL
PARTNERSHIP (MARRIED COUPLE)
Effective Date: From ________________ to
____________________
Producer Code: Phone:
Name of applicant:
Name:
Address:
Address:
City:
City:
State:
Zip Code:
State:
Zip Code:
Name Date of Birth
Occupation
Marital Status Driver License
Number & State
Description of violations and
Accidents (Past 3 years)
Years
Driving
Automobile Physical Damage Insurance
Private Passenger Vehicles Application
Lloyds of London
Phone # 888-495-4950
Fax # 888-997-9970
P.O. Box 8010
Goldsboro, NC 27533-8010
LL-PP 02/13
11. Loss Payee
Veh# Name Address City, State, Zip
12. Previous Insurance and Loss Experience:
13. Car Valuation
Unit # 1
Unit # 2 Unit # 3 Unit # 4 Unit # 5
Year
Make
Mileage
Transmission
Air Conditioning
Yes. No Yes. No Yes. No Yes. No Yes. No
Vinyl Top
Yes. No Yes. No Yes. No Yes. No Yes. No
Power Breaks
Yes. No Yes. No Yes. No Yes. No Yes. No
Power Steering
Yes. No Yes. No Yes. No Yes. No Yes. No
Tinted Glass
Yes. No Yes. No Yes. No Yes. No Yes. No
Type Wheels
Type Radio
Other Equipment
Dealers Quote Cash Price
Dealers Name and Address:
Quotation Made by:
APPLICANT PLEASE READ
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 SIGNATURE
____________________________ ___________ _________ ______________________________________________
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
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Automobile Physical Damage Insurance Private Passenger Vehicles Application (Strickland Insurance Brokers)

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Completed 17 July 2021

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