352.732.4550
Name or Business
E-mail
Tel
Address
Nature of Business
How many Vehicles?
1 2-4 5-9 10-50
Liability Limit?
50000 100,000 300,000 500,000 1,000,000
Uninsured Motorists
50000 100,000 300,000 500,000 1,000,000 Stacked? Yes No
Medical Payments
1,000 2,000 5,000 10,000
Other Coverage
How Many Years in Business?
How many employees?
Enter any claims from the last three years.
Please collect VIN #'s, make, model, body type, year, cost new, gross weight, radius of driving for all vehicles to be quoted. Eventually we will need a list of operators, their date of birth and driver license #'s.
What other commercial insurance would you like us to quote?
LiabilityPropertyWorkers' CompUmbrellaPension Plan BondingEmployee Benefits All
back
insurance@lossingstrickland.com
Copyright © 2002 Lossing Strickland Insurance Group. All rights reserved. Revised: June 12, 2007 .
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Workers' Compensation, Commercial Insurance, Health Insurance,
Life Insurance, Physicians' Medical Malpractice & Estate Conservation
www.propertyinsuranceflorida.com www.commercialinsuranceflorida.com www.generalliabilityflorida.com www.employeebenefitsflorida.com www.lossingstrickland.com
