Hudson CPL Application

Note: We have been quoting / writing Hudson CPL Policies through the wholesaler (3rd party) JE Brown. We will now be placing the policy through a different wholesaler Personal Umbrella.com. Here are the steps to follow.

Step 1: To get a quote, complete this application and email it to the underwriter Cyndy(cnyquist@mymga.com).
Signatures are not required to get a quote. You will receive the formal quote in a few days.

Step 2: If the client wants to purchase the policy, then have the client sign the proposal and application and
email it to the underwriter Mary Nyquist (mnyquist@mymga.com) (Use template number T4001A)

Step 3: Since this is a direct bill policy, then we do not need to collect any money at all. The client will receive a
copy of the policy along with the invoice.

Person Completing form*

The completed PDF form will be emailed to the email address associated with this person

Today's Date*

Date

Completed By (For Email Subject Line)*

Agency Info:

Agency Name*

Street Address*

City*

State*

Zip*

Phone Number*

Fax Number*

Email Address*

Client Info:

What is the Name Insured*

Occupation*

Employers Name*

Prior Occupation If Retired/If Self Employed Name Of Business

Is there an Additional Insured*

What is the Spouse's/Other's/ Co- Applicant Name Insured*

Occupation*

Employers Name*

Prior Occupation If Retired/If Self Employed Name Of Business

Mailing: Address*

Suite/Apt/Unit

City*

State*

Zip*

Policy Information:

Policy Effective Date

MonthDayYear

Policy Expiration Date

MonthDayYear

Requested Limit of Liability

100,000

300,000

500,000

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

Identity Theft Coverage

None

25,000

Medical Payments

1,000

2,000

5,000

Personal Cyber Liability

None

25,000

50,000

Number of resident employees (CA Admitted Only)*

Number of non-resident employees (CA Admitted Only)*

Schedule of Residence Locations (Insured/Applicant Occupied Only):

How many Locations do you want to cover by this Policy

Location 1: Address*

City*

State*

Zip*

What is the Usage of the location

Is this Owner/Applicant Occupied

Is there a Pool in the location

Location 2: Address*

City*

State*

Zip*

What is the Usage of the location

Is this Owner/Applicant Occupied

Is there a Pool in the location

Location 3: Address*

City*

State*

Zip*

What is the Usage of the location

Is this Owner/Applicant Occupied

Is there a Pool in the location

Location 4: Address*

City*

State*

Zip*

What is the Usage of the location

Is this Owner/Applicant Occupied

Is there a Pool in the location

Location 5: Address*

City*

State*

Zip*

What is the Usage of the location

Is this Owner/Applicant Occupied

Is there a Pool in the location

Schedule of Rental Location(Non-Owner Occupied regardless of rent collected):

How many Locations do you want to cover by this Policy

Location 1: Address*

City*

State*

Zip*

Number of Units (Max 4)

Is there a Pool in the location

Location 2: Address*

City*

State*

Zip*

Number of Units (Max 4)

Is there a Pool in the location

Location 3: Address*

City*

State*

Zip*

Number of Units (Max 4)

Is there a Pool in the location

Location 4: Address*

City*

State*

Zip*

Number of Units (Max 4)

Is there a Pool in the location

Location 5: Address*

City*

State*

Zip*

Number of Units (Max 4)

Is there a Pool in the location

Schedule of Land Location:

How many Locations do you want to cover by this Policy

Location 1: Address*

City*

State*

Zip*

Number of Acres*

Number of Parcel (Max 4)

Is there a Pool in the location

Location 2: Address*

City*

State*

Zip*

Number of Acres*

Number of Parcel (Max 4)

Is there a Pool in the location

Location 3: Address*

City*

State*

Zip*

Number of Acres*

Number of Parcel (Max 4)

Is there a Pool in the location

Location 4: Address*

City*

State*

Zip*

Number of Acres*

Number of Parcel (Max 4)

Is there a Pool in the location

Location 5: Address*

City*

State*

Zip*

Number of Acres*

Number of Parcel (Max 4)

Is there a Pool in the location

General Information:

1. Is the applicant or any resident of the applicant's household currently or have they at any time had an occupation as an elected or appointed federal or state political figure, professional athlete or coach, entertainer, media personality, author, artist, TV/Movie producer or a senior executive officer of a publicly traded company?

Yes (Mapping)*

No (Mapping)*

Please Explain

2. Any applicant or household member convicted of insurance fraud (ineligible) and or a Felony (referral)? Provide explanation

Yes (Mapping)*

No (Mapping)*

Please Explain

3. Are any applicants currently insured with Hudson Insurance Group? If so, please provide the policy number(s).

Yes (Mapping)*

No (Mapping)*

Please Explain

4. Any daycare on premise for which compensation is received?

Yes (Mapping)*

No (Mapping)*

Please Explain

5. Any business activities or special eventsconducted on premise?

Yes (Mapping)*

No (Mapping)*

Please Explain

6. Any undomesticated animals in the household or animals with a bite history, security training/fighting or aggressive tendencies?

Yes (Mapping)*

No (Mapping)*

Please Explain

7. Any locations with unfenced pools?

Yes (Mapping)*

No (Mapping)*

Please Explain

8. Any land used for hunting?

Yes (Mapping)*

No (Mapping)*

Please Explain

9. Any other underwriting information or exposures that may increase liabilityincluding but not limited to vineyards, zip lines, skateboard ramps, broken railings,student housing?

Yes (Mapping)*

No (Mapping)*

Please Explain

10. Any farming at any locations? If farmed by insured risk is not eligible. If not farmed by insured, provide type of farming, and confirm person farming the land maintains $1mil GL for their operation.

Yes (Mapping)*

No (Mapping)*

Please Explain

11.Any locations undergoing construction or plans for construction?

Yes (Mapping)*

No (Mapping)*

Please Explain

12. Are any locations owned by an LLC or Trust?

Yes (Mapping)*

No (Mapping)*

You must complete this LLC or Trust questionaire

13. For any non-weather related claims in the last 5 years which meet the below criteria, provide claim description, date of loss, claim status, and paid/reserve amount: Pending litigation, open claims, or any closed nonauto liability claim regardless of payout.

Yes (Mapping)*

No (Mapping)*

Please Explain

14. In the past 5 years, has any coverage been declined cancelled or non-renewed for any reason? Please answer NO if the reasonsare any of the following: carrier leaving the market place, carrier becoming insolvent, or no longer offering coverage due to brushclearance?

Yes (Mapping)*

No (Mapping)*

Please Explain

15. Any other underwriting information of which the Company should be aware?

Yes (Mapping)*

No (Mapping)*

Please Explain

16.Any locations which are 6,000 to 10,000 square feet?

Yes (Mapping)*

No (Mapping)*

Please Explain

17. Any locations which are 10,001 or more square feet?

Yes (Mapping)*

No (Mapping)*

Please Explain

18. Any of the Owner Occupied Location(s) have a Boat Dock?

Yes (Mapping)*

No (Mapping)*

Please Explain

19. Any Long Term Rental location(s) with a boat dock?

Yes (Mapping)*

No (Mapping)*

Please Explain

20. Any Short Term Rental(s) with a boat dock only?

Yes (Mapping)*

No (Mapping)*

Please Explain

21. Any Vacant Land with boat dock?

Yes (Mapping)*

No (Mapping)*

Please Explain

22. Do you currently employ or plan to hire within the next year any residence employee (gardener, housekeeper, nanny, etc) who works more than four hours per week or more than 52 hours in a 90 day period? (California only)

Yes (Mapping)*

No (Mapping)*

Please Explain

23. Any open or closed Workmen's Compensation claims in the past 5 years?(California only)

Yes (Mapping)*

No (Mapping)*

Please Explain