Fillable Printable INSURANCE BINDER SAMPLE

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.