Personal Umbrella or
Excess Liability Policy Application

Today's Date: 08/17/2017
email
Applicant's Name Effective Date
Mailing Address Desired Limit (in millions) $
Residence Address
Producing Office
Producer Name
E-mail
Address
Phone No.
Fax No.
Type Personal Umbrella Personal Excess Liability (Excess over other umbrella*)
Employment
Applicant's Occupation
Applicant's Employer Name and Address.
Years Employed
Co-Applicant's Occupation
Co-Applicant's Employer Name and Address.
Years Employed

Underlying Insurance

Type of Coverage Carrier Policy No. Policy Period Your Underlying Limit
Automobile $
Uninsured/Underinsured $
Homeowner or CPL $
Rental Dwellings $
Farms, Vacant Land $
Watercraft $
Jet Ski, Wet Bike $
Recreational Vehicle $
Underlying Umbrella* $
Incidental Business $
Other $

Real Estate List all owned, leased or occupied Residences, Building, Farms, Vacant Land, etc.

# Location (street,city,state) #Units Yr Built Occupancy (primary, seconday, rental, vacant, etc.)
1
2
3
4
5
6

Automobiles and Recreational Vehicles List all autos owned, leased or furnished for regular use (Motorcycles, Snowmobiles, etc.)

# Year Co. Car? Make/Model/Type # Year Co. Car? Make/Model/Type
1 Yes 2 Yes
3 Yes 4 Yes
5 Yes 6 Yes
7 Yes 8 Yes
9 Yes 10 Yes
11 Yes 12 Yes

Watercraft List all watercarft (including Jet Skis, Wet Bikes, etc.) owned, leased, chartered or furnished for regular use

# Year/Make/Model Length Engine Type/HP Max Speed # of Paid Crew Waters Navigated (inland, coastal, etc.)
1
2
3
4
5
6

Operator Informatioon List Members of Household and all Operators of Vehicles/Watercarfts/RV's

# Name Drivers License # State Date of Birth Vehicle, Craft % of Use
1
2
3
4
5
6

Driving Record Informatioon List # of traffic violations and/or motor vehicle accidents for all Operators indicated above during past 3 years.

# Name # Moving Violations # Major Violations # Minor At-Fault Accidents # Major At-Fault Accidents
1
2
3
4
5
6

General Information - Explain all "Yes" Responses in Remarks (If additional space is needed, please attach a separate sheet)

1) Any liability losses (homeowners, etc) exceeding $5,000 or more in the past 5 years? Yes No 2) Do you employ any residence employees?
Full-time Part-time
# of Employees
Yes No
3) Does any underlying policy have reduced limits of liability or eliminate coverage for specific exposures, drivers, animals, watercraft, locations, etc.? Yes No 4) Do you or any household member have mental/physical impairments that affect driving ability? Yes No
5) Any business/professional activities (including farming or daycare) included in primary policies? Does it cover incidental business activities? Yes No 6) Any umbrella coverage declined, cancelled, or non-renewed in last 5 years? Yes No
7) Do you or any household member hold any non remunerative positions? Details? Yes No 8) Do your underlying insurance policies include Personal Injury (libel/slander) coverage? Yes No
9) Any real estate, vehicles, watercraft, aircraft owned, hired, leased or regularly used, not covered by underlying insurance? Yes No 10) Does any household members have an occupation of a professional entertainer, athlete, media personality or local, state or federal political past or present? Yes No
11) Do any of the properties you own or rent have a swimming pool on premises that have a diving board and/or are not fenced? Any coverage limitations? Yes No 12) Any pets (wild or domestic) on the premises?
Type(s)?
Any coverage restrictions or exclusions? Yes No
Yes No
Remarks - If Yes, explain in this box (Please indicate question# next to explanation)

Optional Uninsured/Underinsured (UM/UIM) Motorist Coverage: (EXTRA CHARGE)

1. I would like to purchase, at additional charge, uninsured/underinsured motorist coverage as part of my Umbrella/Excess Liability policy:
Accept Reject
If you 'accept', then you agree both that you have purchased underlying uninsured/underinsured motorist limits on all other motor vehicles that you own equal or greater than the Minimum Underlying Limits Automobile Liability limits of this policy, and you are electing to purchase certain valuable coverages which protect you and your family, then check this box:
If you 'reject', the uninsured/underinsured motorist coverage, then you agree you have not purchased underlying uninsured/underinsured motorist limits on all other motor vehicles that you own equal or greater than the Minimum Underlying Limits Automobile Liability limits of this policy, or you are electing not to purchase certain valuable coverages which protect you and your family, then check this box:
2. Optional Personal Injury Coverage: Yes No (This requires Personal Injury Coverage on your underlying insurance.)
3. Optional Incidental Business Coverage: Yes No (This requires Incidental Business Coverage on your underlying insurance.)

PRODUCER'S SIGNATURE: ________________________________________ DATE: ______________________

Applicant's Statement: The undersigned applicant declares that if the information supplied on this application changes between the date of this application and the time when the insurance policy is issued, the applicant will immediately notify the insurer of such changes, and the insurer may withdraw or modify any outstanding quotations and/or authorizations or agreement to bind this insurance.

The undersigned applicant further declares that I have read and understand the entire application including the applicable fraud warning, if any, and that the statements set forth in this application are true and complete.

APPLICANT'S SIGNATURE: ______________________________________ DATE: ______________________

Validation Code: 56325
Enter Validation Code:  (Required)

Please submit to my following underwriter


V20090707