Strickland General Agency, Inc.
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1 Strickland General Agency, Inc. P. O. Box 4084 * Duluth, GA * * Fax: Professional Insurance Wholesaler ALABAMA GARAGE DEALER / NON - DEALER APPLICATION Proposed effective date: to Producer: Producer No. Contact: Phone: GENERAL INFORMATION Name of Applicant (include DBA) Applicant is: Individual Joint Venture Partnership LLC Inc. Other Organizational Structure: Mailing Address: Contact: Phone: Website: Contact Number of years in business: Number of years experience in this field: Description of Operations: Location #1 Address Location #2 Address Location #3 Address LIMITS OF LIABILITY AUTO AND OTHER THAN AUTO The most to be paid for any one accident or loss: Combined Single Limit Each Accident $ Aggregate $ (other than auto) No. of Dealer Tags: Combined Auto and Premises Medical Payments Limit $ UNINSURED MOTORISTS COVERAGE This coverage provides protection for persons who are entitled to recover damages because of bodily injury (including resulting death) from an owner or operator of an uninsured motor vehicle, or an insured motor vehicle, whose Liability Coverage limits are less than the insured person's Uninsured Motorists Coverage limits. Basic Limits Accepted as Follows: Single Limit Split Limits Policy Limits Accepted Other Limits Accepted (not to exceed policy limits as follows): Single Limit Split Limits Bodily Injury Each Person Entire Rejection Each Accident UNTIL YOU ADVISE US OTHERWISE IN WRITING, YOUR CHOICE, AS INDICATED ABOVE, WILL CONTINUE REGARDLESS OF ANY ADDITION OR CHANGE IN AUTO COVERAGE ON YOUR CURRENT POLICY OR ADDITION OF ANY SCHEDULED AUTOS AND WILL BE CARRIED FORWARD ON ALL FUTURE RENEWAL POLICIES WITHOUT ADDITIONAL NOTICE. AL GAR APP Page 1 of 5
2 AUTOS TO BE COVERED Symbol 22 - Owned Autos Only Symbol 27 - Specifically Described Autos. List in Section Provided (Requires Additional Premium) Symbol 29 - Non Owned Autos Used In Your Garage Business Type of Business: Used Car Dealer Motorcycle Dealer Repair Shop Wrecker Service Repo Other Used Auto Broker Used Auto Wholesaler INDICATE PERCENTAGE OF THE FOLLOWING TYPE OF AUTOS SOLD / REPAIRED Sales Repair Sales Repair Boats - Other Than Jet Skis Mobile Homes (non-motorized) Golf Carts ATVs, UTVs, Scooters, Snowmobiles Jet Skis Private Passenger Autos, Light & Medium Trucks Kit Cars or Other Auto Manufacturing Recreational Vehicles, Motor Coaches Trailers - Other than Semi Trailers OTHER (Provide complete description): 1. Do you pick up or deliver vehicles out of town? 3. Do you own or use a non-owned tow truck, rollback or other towing device? 4. Do you own or use a non-owned service vehicle? 5. Do you wish to purchase coverage on your haulaway or towing vehicles or devices? 7. Are any of these businesses on same premises as this operation? 8. Do you hire driver services or pick up drivers, such as at Auctions? 9. Do you repossess autos? If yes, how many annually? 10. Do you offer: In-house financing or Buy Here / Pay Here? If yes, titles are transferred to customer At beginning of the finance period 11. Do you have a dog on premises? 15. Do you install trailer hitches? 12. Do you lend vehicles? 13. Do you rent or lease vehicles? 14. Do you hire auto transporters? 15. Do you own or sponsor racing vehicles? UNDERWRITING QUESTIONS TO BE ANSWERED FOR LIABILITY If yes, maximum distance in miles Number of driver trips per month 6. Do you Own, or are you a partner, shareholder, member, or officer of any other business operations? When final payment is made 17. Do you own, operate or service tank trucks/trailers? 2. Do you conduct business and/or drive outside of your base state? If yes, explain & list States: 16. Do you handle or sell LP gas? 18. Do you engage in auto dismantling? 19. Do you engage in tire recapping? UNDERWRITING QUESTIONS TO BE ANSWERED FOR GARAGEKEEPERS LIABILITY 1. Are vehicles locked and inside fenced area? 2. Are keys to vehicles kept in locked cabinet or safe when business is closed? 3. Do you have a central station alarm? 4. Do you want cargo or on hook coverage for vehicles you tow or haul? 5. Do you do road service? UNDERWRITING QUESTIONS TO BE ANSWERED FOR PHYSICAL DAMAGE 1. Are your premises subject to flood or rising waters? 2. Is your lot: Completely Fenced & Locked Post-Chained & Locked Floodlighted Unprotected Openings All Autos Stored in Locked Building when Business is Closed 3. Keys to Vehicles: Take Home Kept in Locked Cabinet Keys Kept in Locked Safe Other (Describe) 4. Do you have a Night Watchman? Alarm System? 5. Do you or a salesman accompany customer on test drives? 6. Do you allow extended or overnight test drives? 7. Do you photocopy or verify Customer's Driver's License and Insurance ID Card? If No, why not? AL GAR APP Page 2 of 5
3 PHYSICAL DAMAGE (DEALERS OPEN LOT) 100% COINSURANCE REQUIRED Limit Location #1 $ Maximum cost any one auto $ Deductible per auto $ Maximum Deductible Limit Location #2 $ Maximum cost any one auto $ Deductible per auto $ Maximum Deductible Limit Location #3 $ Maximum cost any one auto $ Deductible per auto $ Maximum Deductible Collision Comprehensive Location Address List all lienholders by name and address Additional Insured's: Relationship to Insured Name: Address: GARAGEKEEPERS LIABILITY $ Each Location (Maximum value all vehicles in your care, custody and control) $ Maximum any covered auto $ Deductible each covered auto $ Maximum Deductible Legal Liability Direct Primary Collision Comprehensive OPTIONAL COVERAGE "Yes" answer requires payment of additional premium False Pretense Yes No $ Limit Consigned Autos Yes No $ Limit If "Yes" answer to consigned autos, we must have a copy of consignment agreement. Please attach to application EMPLOYEE AND NON-EMPLOYEE INFORMATION Loc. # Name Drivers License of Violations or Job Description or Relationship Number Birth Accidents to Insured & within the State Past 3 years (see below) Full Time or Part Time (see below) Furnished an Auto for Personal Use? Yes / No Have all owner, employees, non-employees, household members and drivers who may operate your vehicles or vehicles in your care, on a regular or infrequent basis been disclosed above? Yes No JOB DESCRIPTION OR RELATIONSHIP TO INSURED: Owners, Partners, Officers, Salespersons, Managers Clerical staff, Lot personnel, Mechanics Contract Driver - provide name(s), or Blanket Contract Drivers Inactive Owners, Inactive Partners, Inactive Officers Non-Employee - Spouse, Domestic Partner, Children PART TIME: Employees working less than 20 hours per week shall be considered Part Time LIST ALL INDEPENDENT CONTRACTORS AND SUB CONTRACTORS AND THEIR EMPLOYEES AL GAR APP Page 3 of 5
4 SPECIFICALLY DESCRIBED AUTOS, TOW TRUCKS, ROLLBACKS, CAR TRAILERS, OR OTHER TOWING DEVICE TO BE SPECIFICALLY INSURED. REQUIRES ADDITIONAL PREMIUM Unit Model Vehicle Vehicle Weight Stated No. Year Make Model Identification # (GVWR) Value Radius Body Type THREE - YEAR PRIOR CARRIER AND LOSS HISTORY Current Carrier Policy Period Policy Premium Prior Carrier Policy Period Policy Premium Prior Carrier Policy Period Policy Premium If there is no prior insurance, check here If there is no prior losses, check here of Loss Amount Paid / Reserve Description of Loss including Driver I hereby authorize the prospective Insurer to obtain from the Department of Public Safety a copy of my Motor Vehicle Report for use in rating and/or underwriting the insurance for which I do hereby apply and any renewal thereof. I understand that in obtaining a Motor Vehicle Report, a consumer reporting agency may be used by the insurer and I do hereby authorize such use. I hereby certify that the named drivers under this policy (names specified on application and/or drivers hired during the term of this insurance) have or will have authorized me to consent on their behalf for the insurer to obtain Motor Vehicle Reports for rating and/or underwriting. Signature of Applicant PREMIUM BILLING INSTRUCTIONS Agency Bill Premium Financed PREMIUM $ TAX $ INSP. FEE $ TOTAL $ Check No. Check Amt.$ Down Payment $ ** # of Payments ** ** Entries here authorize Strickland General Agency, Inc. to sign on my behalf premium finance agreement financing the premium for the policy(ies) for which I am applying and to sign premium finance agreements financing renewals or rewrites of that policy and I understand such premium finance agreements contains power of attorney enabling the premium finance company to cancel any insurance contract listed in the agreement. Signature of Applicant AL GAR APP Page 4 of 5
5 AGREEMENT FOR BINDING ARBITRATION AND WAIVER OF JURY TRIAL THE UNDERSIGNED APPLICANT OR INSURED, ON BEHALF OF HIMSELF OR HERSELF AND ALL PERSONS WHO MAY BECOME INSUREDS UNDER ANY POLICY RESULTING FROM THIS APPLICATION, AND STRICKLAND GENERAL AGENCY, INC., PREMIUM FINANCE COMPANY, INSURANCE CLAIMS MANAGEMENT, INC., THEIR OWNERS, SHAREHOLDERS, OFFICERS, SERVANTS, OR EMPLOYEES, AND ANY INSURANCE COMPANY WITH WHICH THIS INSURANCE IS BOUND OR A POLICY IS WRITTEN, AGREE THAT ANY AND ALL DISPUTES, CONTROVERSIES OR CLAIMS ARISING OUT OF OR RELATING TO ANY TRANSACTION OR THE CONSTRUCTION, PERFORMANCE, OR BREACH OF THIS OR ANY OTHER AGREEMENT BETWEEN THEM, WHETHER ENTERED INTO PRIOR TO, ON, OR SUBSEQUENT TO THE DATE HEREOF, SHALL BE RESOLVED EXCLUSIVELY BY ARBITRATION IN ACCORDANCE WITH THE FEDERAL ARBITRATION ACT AT 9 U.S.C.SECTION 1. EITHER PARTY MAY MAKE A WRITTEN DEMAND FOR ARBITRATION. WHEN THIS DEMAND IS MADE, EACH PARTY WILL SELECT AN ARBITRATOR. THE TWO ARBITRATORS WILL SELECT A THIRD. IF THEY, THE ARBITRATORS, CANNOT AGREE WITHIN 30 DAYS, EITHER THE ARBITRATORS OR THE PARTIES MAY REQUEST THAT A JUDGE OF A COURT HAVING JURISDICTION MAKE THE SELECTION. EACH PARTY WILL: 1. PAY THE EXPENSES IT INCURS, AND 2. BEAR THE EXPENSES OF THE THIRD ARBITRATOR EQUALLY. UNLESS BOTH PARTIES AGREE OTHERWISE, ARBITRATION WILL TAKE PLACE IN THE LARGEST CITY IN THE STATE WITH JURISDICTION. LOCAL RULES OF LAW AS TO PROCEDURE AND EVIDENCE WILL APPLY. A DECISION AGREED TO BY TWO OF THE ARBITRATORS WILL BE BINDING. SIGNATURE OF INSURED OR APPLICANT DATE AL GAR APP Page 5 of 5
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