LLGKLL JAN 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
Garagekeepers Address Location: ______________________________________________
1.
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
Yes No
Yes No
2. 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
If No, explain procedure of handling ______________________________
3. 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 have you across exits and entrances? Describe fully:
_______________________________________________________________________
e) Any other protections (Lights, Dogs, Watchmen etc)
_______________________________________________________________________
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:
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 2
Lloyds of London
Supplement Additional Location
Phone # 888-495-4950
Fax # 888-997-9970
P.O. Box 8010
Goldsboro, NC 27533-8010
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