Fillable Lloyds of London Garagekeepers On-Hook (Strickland Insurance Brokers)

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Lloyds of London Garagekeepers On-Hook (Strickland Insurance Brokers)

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The Lloyds of London Garagekeepers On-Hook (Strickland Insurance Brokers) form is 2 pages long and contains:

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  • 2 check-boxes
  • 164 other fields

Country of origin: US
File type: PDF

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LL JAN GKLL/OH 2013 1
ASSURED WARRANTS THAT ALL STATEMENTS MADE IN THE PROPOSAL ARE TRUE, COMPLETE AND HAVE BEEN MADE TO
INDUCE UNDERWRITERS TO ACCEPT THE RISK(S) CONTAINED IN THE POLICY. ANY MISREPRESENTATION WILL VOID THE
POLICY AND FORFEIT ALL CLAIMS MADE THEREUNDER. A COPY OF THIS PROPOSAL WILL BE INCORPORATED IN THE POLICY
AND FORM THE BASIS OF THE CONTRACT BETWEEN THE UNDERWRITERS AND THE ASSURED AND SUBJECT TO
COINSURANCE
Effective Date: From ________________ to ____________________
QUESTIONS OR STATEMENTS:
1. Coverage requested Garagekeepers Types of units stored _____________________________
On-Hook
2. Describe Business Operations:
3. Does the insured do any Repossessions? Yes No
4. Location(s) at which Insurance applies: Location 1:_________________________________________
.
5. What is the Radius for Pick-up and delivery?
6. How many years have you operated the business being proposed for insurance? (Include in your answer previous business of a similar nature, which may have
been operated under a different name or corporate structure stating the previous business title)
A. At the above location(s) (previous name)
________________________ ____________________________________
B. At any other location(s) (previous name)
________________________ ____________________________________
7. Nature of Location(s)
Are units stored in:
a. A closed building
b. An open lot
c. Other than above (parking lot, building with open lot or forecourt),
If so, please describe:____________________________________________________
Yes No
Yes No
Yes No
8. a) Are premises unattended at any time during the day or night? Yes No
b) Number of entrances _____________________
c) Are keys left in ignition? Yes No
If No, explain procedure of handling ______________________________
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:
Lloyds of London
Garagekeepers On-Hook
Phone # 888-495-4950
Fax # 888-997-9970
P.O. Box 8010
Goldsboro, NC 27533-8010
LL JAN GKLL/OH 2013 2
9. If Open Lot
a) Is the lot completely fenced or surrounded by buildings on all four sides? Yes No
If not fenced, state what protections you have:
Front _____________________________________________________
Rear _____________________________________________________
Left Side _____________________________________________________
Right Side _____________________________________________________
b) Are exits and entrances properly supervised? Yes No
c) Height and type of fence or wall ____________________________
d) What protection against theft do you have across exits and entrances? Describe fully:
_______________________________________________________________________
e) Any other protections (Lights, Dogs, Watchmen etc)
_______________________________________________________________________
10. Has your insurance been declined in the past three years? If yes, explain Yes No
______________________________________________________________
Veh # Year Make/Model Body Type
Loaded
GVW
Vehicle Identification
Number
On-Hook
Limit
Deductible
13. Owner/Employee Information
14. Previous Insurance and Loss Experience
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
____________________________ _______ ____ __ _____________________________________________________
11. Storage Limit
Maximum No. of
units that your
location(s) will
accommodate
Average
Value
per Unit
Maximum
Value
per Unit
Average No. Of
Units
Maximum No. Of
Units
Limit required
Deductible
Each and every
loss/ Each and
every unit
Location 1
12. On-Hook
Owner Employee Name Date of Birth
Years of commercial
Driving experience
Driver License
Number & State
Description of violations and
Accidents (Past 3 years)
Policy Period Insurance Carrier Policy #
Number
of Claims
Total
Amount
Paid Hail
Total
Amount
Paid
Windstorm
Total
Amount
Paid
Collision
Any
other
Physical
loss
Open
Claims
From To
From To
From To
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Completed 17 July 2021

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