Strickland General Agency of TN, Inc.                                                                    Garage E-Z Quote Form TN

* Signifies a REQUIRED Field

* Agency #:    * Contact:    * Phone:    * State:

* Agency Name:

* Applicant Name:

* Location:

Trade Name:

* County:    * Individual    * Partnership    * Corporation    Expiration Date:    * Years in Business:  

* Business of Insured:     * Total Number of Employees:

* Sell Auto Parts New or Used: Yes No    * Operate a Salvage Yard: Yes No  * Any Garage Operations at other Locations: Yes No

* Any Other Business Operations on same premises Owned by Insured: Yes   No

* Do you own a: Wrecker Yes    No   Rollback        Yes    No    * Do you own or use: Tow Bar or Tow Dollie or Trailer:            Yes   No                                       

* Previous Policy Cancelled:Yes    No    Previous Policy Non-Renewed:Yes    No

* Present Carrier:

Loss History

* Date of Loss                                                    * Details                                                                                                           * Amount Paid

       

        

            

Garage Limits of Liability:    

Med Pay Limits:    

ALL OTHER STATES:    Uninsured Motorist

    Uninsured Motorist   

    Reject Uninsured Motorist 

  If Uninsured Motorist is accepted, then # of Dealer Plates:  

Radius of Operation: 

Garage Keepers Coverage - Vehicles of others in the care, custody or control of the applicant.

Legal Liability    Direct Primary    Total Value per Lot:Cannot not exceed $500,000   Deductible:

Max Limit any 1-Unit:Cannot exceed $30,000 per unit     Specified Perils    Collision    Comprehensive

Physical Damage Coverage - All vehicles under title or bill of sale owned by the applicant

Total Value per Lot:Cannot exceed $500,000    Max Limit any 1-Unit:Cannot exceed $30,00 per unit

Deductible:    Specified Perils    Collision    Comprehensive

Security Devices

Lot Chained:Yes    No    Lot Fenced:Yes    No    Lot Other:Yes    No - Explain:

Where are Keys Kept:    Lot Lighted at Night:Yes    No

* Owners / Spouses / Driver / Employees / Person furnished Autos

* Owner & Spouse Name(s) &  Age:

* Drivers Name(s) & Age:   

* Employee Name(s) & Age:   

*Persons Furnished Autos:   

* Any children in household:Yes    No    If Yes, need all ages:

Comments: