STRICKLAND GENERAL AGENCY, INC.                  

Excess Umbrella

* Signifies a REQUIRED Field

AGENCY INFORMATION

* Agency Name:    

* Agency #:

Agency Contact:

E-Mail:                

APPLICANT INFORMATION

* Applicant (first named insured):

* Proposed Effective Date:    * Proposed Expiration Date:

Date Business Started:

PREMISES INFORMATION

Street:

City:    State:    Zip Code:

County:    Year Built:

Gross Sales:    Annual Payroll:    # of Employees:

Nature of Operation:

Excess Limits Desired:

UNDERLYING INSURANCE

Has any Policy or Coverage ever been Declined, Cancelled or Non-Renewed:Yes    No

General Liability Prior Carrier:

Policy Term:    Policy Limits:(minimum required - 1mil / 2mil / 1mil)

Current Premium Quoted:

Automobile Liability Prior Carrier:

Policy Term:    Policy Limits:(minimum required - 1mil )

Current Premium Quoted:

Employer Liability Prior Carrier:

Policy Term:    Policy Limits:(minimum required - 500 / 500 / 500 )

Current Premium Quoted:

VEHICLES

Private Passenger

                  # Owned:    Property Hauled:    Miles:

Trucks:

       Light - # Owned:    Property Hauled:    Miles:

   Medium - # Owned:    Property Hauled:    Miles:

      Heavy - # Owned:    Property Hauled:    Miles:

 Ex-Heavy - # Owned:    Property Hauled:    Miles:

Trucks/Tractors:

      Heavy - # Owned:    Property Hauled:    Miles:

 Ex-Heavy - # Owned:    Property Hauled:    Miles:

Buses:

                  # Owned:    Property Hauled:    Miles:

HABITATIONAL - (Apartments, Dwellings, Hotel)

Number of Stories:    Number of Units:

Any Government Subsidized Housing:Yes    No    If Yes, what percentage:

Any Student Housing:Yes    No    If Yes, what percentage:

Construction Type:

Smoke detectors HARD WIRED with battery backup:Yes    No

Building has sprinkler system:Yes    No    If yes, what percentage of the structure:

If original structure is over 15 years of age, indicate date of last update to:

Roof:    Electrical:    Heating/Cooling System:

Other:

Is there a swimming pool:Yes    No    If yes, is there a slide or diving board:Yes    No

LOSS HISTORY

Date of Loss:    Amount Paid:

Details:

Date of Loss:    Amount Paid:

Details:

Date of Loss:    Amount Paid:

Details:

ADDITIONAL INSTRUCTIONS OR COMMENTS