STRICKLAND GENERAL AGENCY of FL, INC.                                 "QUICK QUOTE" / COMMERCIAL AUTO

    Trucks

Agency Fax:     Agency #:                                       Applicant Expiration Date:    Years in Business:

Agency:    E-Mail:

New Venture:Yes    No    DOT #:    If Yes, then list who you have driven for or been leased to for the past 4 years:

Applicant: 

Location:    City:    State:    Zip Code:

Business / Commodities Hauled:

Present Carrier:

Carrier / 4-Years Prior:

Has Insured ever been Cancelled or Non-Renewed within the Past 5 Years:Yes    No

Date of Loss                                                                                                Details                                                                                                                         Amt Paid

                                            

Radius / Zones:   

Miles Driven by State for the most current 12 Months:

AK:    AL:    AZ:    AR:    CA:    CO:    CT:    DE:    DC:

FL:    NFL:    SFL:    GA:    ID:    IL:    IN:    IA:    KS:

KY:    LA:    ME:    MD:    MA:    MI:    MN:    MS:    MO:

MT:    NE:    NV:    NH:    NJ:    NM:    NY:    NC:    ND:

OH:    OK:    OR:    PA:    RI:    SC:    SD:    TN:    TX:

UT:    VT:    VA:    WA:    WV:    WI:    WY:

Limits of Liability:    *Other:    Un-Insured Motorist:    *Other:    MedPay:

Motor Truck Cargo: Limits per Unit:    Deductible:

Driver(s):           Name                                                                   DOB               Yrs Exp                        Violations                                                   Accidents

                                                                               

Are Filings Required:Yes    No    If Yes, List:

Schedule of Equipment:

 Year                                               Make                                                           GVW                              Type                                               Value                                      Ded 

                   

                     

                    

                     

                     

   

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