INSURANCE BINDER SAMPLE

INSURANCE BINDER
SLIB0608
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT. SUBJECT TO THE CONDITIONS SHOWN AT THE BOTTOM OF THIS FORM
COMPANY:
Service Lloyds Insurance Company
P.O. Box 26850
Austin, Texas 78755-0800
DATE ISSUED
:
POLICY NO
:
INSURED:
AGENT:
EFFECTIVE 12:01A.M.:
EXPIRATION
12:01 A.M.:
COVERAGE: Coverage A - Contractual Liability and
Coverage B - Employer’s Liability
Limits of Liability – Combined Single Limit
Each Employee: $ 1,000,000
Each Occurrence $ 5,000,000
Policy Aggregate $25,000,000
Self Insured Retention: $ 2,500
Indemnity Period 156 weeks Weekly Indemnity (Maximum) $700
AUTHORIZED REPRESENTATIVE:
__________________________________
CONDITIONS
This Company binds the kind of insurance stipulated above. The Insurance is subject to the terms, conditions and
limitations of the policy in current use by the Company. Subject to active safety plan
This binder may be cancelled by the Insured by surrender of this binder or by written notice to the Company stating when
cancellation will be effective. This binder may be cancelled by the Company by notice to the Insured in accordance with the
policy conditions. This binder is cancelled when replaced by a policy. If this binder is not replaced by a policy, the
Company is entitled to charge a premium for the binder according to the Rules and Rates in use by the Company.
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