LL DRIVER 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
NOTE: THE POLICY, IF ISSUED. WILL BE SUBJECT TO LIMITS OF LIABILITY AT EACH LOCATION, A LIMIT OF ANY ONE UNIT
AND SUBJECT TO COINSURANCE
Additional Driver Information
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
_____________________________ ___________ ____________ _____________________________________
Name of applicant
Producer Code: Phone:
DBA
Name:
Address:
Address:
City:
City:
State:
Zip Code:
State:
Zip Code:
Name Date of Birth
Years of
commercial
Driving
experience
Driver License Number &
State
Description of violations and Accidents (Past 3
years)
Lloyds of London
Phone # 888-495-4950
Fax # 888-997-9970
P.O. Box 8010
Goldsboro, NC 27533-8010
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