Personal Umbrella Insurance Form

Personal Umbrella Insurance Form - Florida
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the location same as the mailing address?*

YesNo
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy and Coverage information
Current Carrier*
Umbrella Limit Requesting*

1,000,0002,000,0003,000,0004,000,0005,000,000Other
How many automobiles are owned (titled or registered to), leased, rented, or regularlyoperated by you or any member of your household?*
Do not count antique, classic or collectible automobiles
How many residential properties - regardless of location - are owned by or rented toyou or any member of your household?*
Do not include residential properties thatare covered under a Commercial General Liability Policy or other non-personalPremises Liability Policy because they are excluded from coverage.
How many watercraft between 14 and 45 ft., including any extensions to the hull, areowned or regularly operated by you or any member of your household?*
Do notcount watercraft exceeding 45 feet. Do not count watercraft powered by a totalcombined horsepower rating that exceeds 300 AND is also capable of speeds inexcess of 50 mph. Watercraft exceeding these limitations are excluded from coverage.(Do not count canoes, Jet Skis, Waverunners or other personal watercraft)
How many Jet Skis, Waverunners or other personal watercraft are owned or regularlyoperated by you or any member of your household?*
What is the total number of drivers?*
Include drivers with a learner's permit orvalid driver's license
How many drivers are under the age of 22?*
Include drivers with a learner’s permit orvalid driver’s license.
How many drivers are age 70 or over?*
Include drivers witha learner’s permit or valid driver’s license.
How many moving violations have all drivers had within the last 3 years?*
Include DWI/DUI incidents within the last 5 years
How many at-fault accidents have all drivers had in the last 3 years?*
How many antique, classic or collectible automobiles are owned (titled or registered to) by you or any member of yourhousehold?*
Of the number of residential properties from question 2, how many residential properties owned by or rented to you or anymember of your household are located outside of the U.S. (including its territories and possessions) or Canada?*
How many acres of land do you or any member of your household own or lease (including partial ownership)? Max. of 1280acres.*
Do not include land that is covered under a Commercial General Liability policy or other non-personal Premises LiabilityPolicy because they are excluded from coverage.
How many drivers have been licensed to drive in the U.S. less than one year, currently have a learner's permit, and/or have anon-U.S. driver's license? *
A year or more with a learner's permit does not qualify as a year with a driver's license. (Max. of 8)
How many driving incidents have all drivers ages 21 and under and/or 80 and over had within the last 3 years?*
(Max. 1 perdriver)
How many arrests, citations or license suspensions for driving under the influence of alcohol/drugs, driving while intoxicated and/orany other alcohol/drug related incidents have all drivers had in the last 5 years?*
(Max. 1 per household for drivers between ages22 and 79; 0 per household for drivers under ages 22 and 80 or over.)
Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving (with 4 points inFlorida), negligent driving and/or had a driver's license suspended (for reasons other than driving under the influence ofalcohol or drugs), revoked or refused in the last 5 years?*

YesNo
Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years?*

YesNo
Are you or any member of your household recognized nationally or locally as a celebrity or famous person? (professional entertainer, athlete, media personality, etc.)

YesNo
Have you or any member of your household had a liability loss greater than $50,000 in the past 5 years or are you or anymember of your household aware of any facts, circumstances, incidents, or accidents that could give rise to a claim orlawsuit, whether valid or not, which might directly or indirectly involve you or any member of your household?*

YesNo
Does any other member of your household or other person residing in your household have a Personal Umbrella policywith RLI Insurance Company other than this policy?*

YesNo
Has any one driver had more than 3 moving violations in the last 3 years? (Include DWI/DUI incidents within the last 5years.)*

YesNo
Has any one driver ages 21 and under or 80 and over had more than one driving incident within the past 3 years?*

YesNo
Do you elect to purchase or reject Excess UM/UIM coverage? (select one) Submission of a state mandated form supersedes any response to this question*

PURCHASEREJECT
Which of the following MINIMUM REQUIRED LIMITS OF LIABILITY do you and ALL members of your household agree tomaintain as a condition of coverage during the Policy period?*

$100,000$300,000 or Higher
Which of the following MINIMUM REQUIRED LIMITS OF AUTOMOBILE LIABILITY do all drivers agree to maintain as a condition ofcoverage for all automobiles that are owned (titled or registered to), leased, rented, operated or acquired during the policy period byyou or any member of your household?
Limit A*

Limit A $500,000 Bodily Injury per person/ $500,000 Bodily Injury per occurrence/ $50,000 Property Damage per occurrence$500,000 Combined Single Limit per occurrence
Limit B (The choice of Limit B results in a higher premium.)*

$250,000 Bodily Injury per person/ $500,000 Bodily Injury per occurrence/ $50,000 Property Damage per occurrence$300,000 Bodily Injury per person/ $300,000 Bodily Injury per occurrence/ $50,000 Property Damage per occurrence$300,000 combined single limit per occurrence
Limit C (The choice of Limit C results in a higher premium. Excess UM/UIM is NOT available if you maintain Limit C.) Note: Limit C is available ONLY if all drivers in the household are age 22 and over. Limit C is NOT available if there are any drivers age70 or over; and/or if any response makes the risk Standard II; and/or if any response makes the risk PUP Special.*

$100,000 Bodily Injury per person/ $300,000 Bodily Injury per occurrence/ $50,000 Property Damage per occurrence
Complete the following for all drivers AND members of your household ages 14 and older. Per the definition of driver, also include any other personwho operates an automobile owned (titled or registered to), leased, rented or regularly operated by you or a member of your household at least 50%or more of that automobile's use. Individuals listed below are for determining policy eligibility; if a policy is issued, coverage for each is determinedpursuant to the Policy Provisions.*
Reffered by?*
Should be Empty:

Personal Umbrella Insurance Form - Florida

Personal Information

Policy and Coverage information

Which of the following MINIMUM REQUIRED LIMITS OF AUTOMOBILE LIABILITY do all drivers agree to maintain as a condition ofcoverage for all automobiles that are owned (titled or registered to), leased, rented, operated or acquired during the policy period byyou or any member of your household?