Strickland General Agency, Inc.                                                                                                                                      

* Signifies a REQUIRED Field                                                                               E-Z Quote General Liability - Property - Package

General Liability    Property    Package (Liability & Property)

General Information

* Agency #:    * Agency Name:       

* Contact:    E-mail:   

* Applicant Name:

*Operation Location Address: 

* City:  * State:   *Zip Code:

* Applicant is:    Other Explain:

*Complete Description of Operation:

Liability Coverage

Applicant is the:    What type of equipment do you use in your operation (job):

Payroll not including Owners: Payroll including Owners: Sales: Total Amount Subbed Out:

How long have you been in business:    How much experience do you have:    Do you use subcontractors:Yes    No

What type work do you subcontract:

What amount work do you subcontract:$    Do you obtain certificates:Yes    No   

Number of Losses have you had in the past 3 years:  Company that previously insured you:

Has you insurance been:Declined    Canceled    If so, why:

What limit of liability and coverage do you want:

Class Code                                                                                            Class Description

  

 

 

Property Limits

Building Limit -1:  Contents:  Deductible:    Protection Class:   

Year Built:    Square Footage:

Coinsurance: 80%    Updates: Roofing:   Electrical Wiring:  Plumbing:  Construction:

Physical Location:

City:  State:   Zip Code:

Building Limit -2:  Contents:  Deductible:    Protection Class:   

Year Built:    Square Footage:

Coinsurance: 80%    Updates: Roofing:   Electrical Wiring:  Plumbing:  Construction:

Physical Location:

City:  State:   Zip Code:

Coverage Form

ACV   

Replacement Cost - BUILDING ONLY - Risk not over 30 years of age.  Roof, Electrical and Plumbing updated in last 10 years to qualify.

Central Station Alarm - Policy will contain Warranty - Copy of Installation Certificate required

Mortgage / Loss Payee:

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