J.M. Strange & Company -- Insurance * Bonds

Disclaimer

Please note completion of any request(s) for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting a request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.  I have read and agree with the above disclaimer.   (Box must be checked before request can be sent)

Personal Information
Name:
Address:
City:	State:   Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM   PM
Email Address:
Best Contact Time:
EMPLOYMENT INFORMATION
Applicant's Occupation	Employer Name/Address	Yrs Empl.
Co-Applicant's Occupation	Co-Applicant's Employer Name/Address	Yrs Empl.

Umbrella Information
COVERAGES
Policy Amount	Retention	Optional Coverages to Apply
$	$	$ Uninsured Motorist	$ Underinsured Motorist
PREMIUMS
PLEASE NOTE:    In order to calculate total premiums below, please leave "0" amount in any field below where you have no dollar amount to enter
Basic:		$
Residences:		$
Automobiles:		$
Recreational Vehicles:		$
Uninsured Motorist:		$
Underinsured Motorist:		$
Watercraft:		$
		$
		$
TOTAL:		$

Primary Policy Information
Type of Policy	Company/Policy Number	Policy Period	Limits of Liability
			Single Limit	Bodily Injury	Property Damage
Automobile			$	$	$
Personal  Liability			$	$	$
Watercraft			$	$	$
Recreational  Vehicles			$	$	$
			$	$	$
			$	$	$

Real Estate
#	Name	Location	Description	Yr Built	Occupancy
(1)
(2)
(3)
(4)
(5)

Automobiles			Recreational Vehicles
List All Autos Owned, Leased, or Furnished for Regular Use			List Motorcycles, Snowmobiles, Dune Buggies, MiniBikes, Etc.
#	Year	Make and Model	#	Year	Type, Make and Model
(1)			(1)
(2)			(2)
(3)			(3)
(4)			(4)
(5)			(5)

Watercraft
List All Watercraft Owned, Leased, Chartered, or Furnished for Regular Use
#	Year	Type/Manufacturer/ Model	Length	Horse Power	Max Speed	Value	Waters Navigated
(1)						New  Current
(2)						New  Current
(3)						New  Current

Operator Information
List all Household Members & All Operators of Vehicles/Watercraft
#	Name	DOB	Auto DL#/State Licensed	Vehicle, Craft, % Use, Etc.
(1)
(2)
(3)
(4)
(5)

Prior Experience/Losses
#	Please List Losses on Any Primary or Excess Policies Exceeding $5,000 During the Last 5 Years	Carrier and Policy Number
(1)
(2)
(3)
(4)
(5)

General Information

(1) Any Aircraft Owned, Leased, Chartered, or Furnished for Regular Use?

Yes   No       If "Yes", please explain below:

(2) Any Operators Convicted for any Traffic Violations During the Last 3 years?

Yes   No       If "Yes", please explain below:

(3) Any Operator Have Physical/Mental Imparement?

Yes   No       If "Yes", please explain below:

(4) Any swimming pool on premises?

Yes   No       If "Yes", please explain below:

(5) Any Real Estate, Vehicles, Watercraft, Aircraft Used Commercially of for Business Purposes.?

Yes   No       If "Yes", please explain below:

(6) Any Real Estate, Vehicles, Watercraft, Aircraft, Owned, Hired, Leased, or Regularly Used, Not         Covered by Primary Policies?

Yes   No       If "Yes", please explain below:

(7) Do You Engage In any Type of Farming Operation?

Yes   No       If "Yes", please explain below:

(8) Do You Hold any Non-Remunerative Positions?

Yes   No       If "Yes", please explain below:

(9) Any Full-Time Employees?   (Please Add Number of Employees)

Yes   No       If "Yes", please explain below:

(10) Any Non-Owned Property Exceeding $1,000 in Value, in Your Care, Custody, or Control?

Yes   No       If "Yes", please explain below:

(11) Any Business and/or Professional Activities Included in the Primary Policy?

Yes   No       If "Yes", please explain below:

(12) Does any Primary Policy Have Reduced Limits of Liability or Eliminate Coverage for Specific Exposures?

Yes   No       If "Yes", please explain below:

(13) Any Coverage Declined, Cancelled, or NonRenewed During the Last 5 Years?

Yes   No       If "Yes", please explain below:

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

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