Fillable Charge in addition to the premium Insurance Company: (Strickland Insurance Brokers)

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Charge in addition to the premium Insurance Company: (Strickland Insurance Brokers)

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P.O. Box 8010, Goldsboro, North Carolina 27533-8010
Phone 888-495-4950 Fax 888-997-9970
Charge in addition to the premium
Insurance Company: United States Liability Insurance Company
Named Insured: ____________________________
Description of Insurance: _________________________
Policy Number: _______________________
Policy Period: __________________
As provided for in North Carolina General Statute 58-33-85(b), I hereby
consent to pay a fully earned fee of $_________ to Strickland Insurance
Brokers, Inc for the rendering of services associated with the policy
referenced above. Further, I understand that this fee is in addition to the
policy premium.
Insured’s Signature:
Date:
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Charge in addition to the premium Insurance Company: (Strickland Insurance Brokers)

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Completed 17 July 2021

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