Personal Umbrella Insurance Questionnaire

Personal Umbrella Insurance Questionnaire

Please fill the form as completely as possible for better assistance. The email box that this form is submitted to is monitored continuously and someone will be in touch with you very shortly once the form is submitted. All Data is encrypted. Landsman Insurance Services, LLC. NPN: 21500715 - 1-833-208-0034
Applicant Information
Full Name*

First NameLast Name
Co-Applicant Full Name

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Driver's License #?
Co-Applicant Date of Birth

MonthDayYear
Date
Co-Applicant Driver's License #?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How many automobiles are licensed for road use in your household?
How many residential properties in your household?
How many watercraft, OTHER than personal watercraft (WaveRunners, Jet Skis, etc.),are in your household?
What is the total number of drivers? (Include drivers with a learner's permit or valid driver's license)
How many drivers are under the age of 22? (Include drivers with a learner's permit)
How many drivers are age 70 and over?
How many drivers are age 80 and over?
How many moving violations have ALL drivers had within the last 3years? Include DWI/DUI violations 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 orregistered to) by you or any member of your household? (Max. of 25)
Of the number of residential properties from question 2, how many residentialproperties owned by or rented to you or any member of your household arelocated outside of the U.S. (including its territories and possessions) orCanada? (Max. of 5)
How many acres of land owned or leased (including partial ownership)?
How many drivers have been licensed less than one year, have a learner's permit, or have a non-U.S. driver's license?
How many driving incidents have all drivers ages 21 and under had within the last 3years?
How many driving incidents have all drivers ages 80 and under had within the last 3years?
How many alcohol/drug related driving incidents have all drivers had in the last 5 years?
An umbrella policy for general liability covers YOUR liability but does not cover Uninsured Motorists (UM) Coverage which is typically part of your standard auto policy. Uninsured Motorists (UM) Coverage pays you (and passengers) if you’re injured by a driver who has no insurance at all. Underinsured Motorists (UIM) Coverage: This pays you if the at-fault driver has insurance, but not enough to cover your damages. Excess Uninsured/Underinsured Motorists Coverage: This is an optional higher limit you can buy above the basic UM/UIM limits. Do you elect to purchase Excess Uninsured/Underinsured Motorists coverage in addition to excess liability?

Yes, I wish to elect this coverage.No, I do not wish to elect this coverageI'm not sure. I'd like to see options and pricing.
Which of the following MINIMUM REQUIRED LIMITS OF AUTOMOBILE LIABILITY do all drivers agree to maintain as a condition of coverage for all automobiles that are owned (titled or registered to), leased, rented, operated or acquired during the policy period by you or any member of your household? If you elect to purchase Excess Uninsured/Underinsured Motorist (UM/UIM) coverage, the Required Basic UM/UIM policy limits must be equal to the liability limits for the required Basic Automobile Liability Policy. You agree that this condition applies equally to personal use of an automobile covered under a Commercial Automobile Liability.

$500,000 Bodily Injury per person/ $500,000 Bodily Injury per occurrence/$50,000 Property Damage per occurrence OR $500,000 Combined Single Limit per occurrence$250,000 Bodily Injury per person/ $500,000 Bodily Injury per occurrence/ $50,000 Property Damage per occurrence OR $300,000 Bodily Injury per person/ $300,000 Bodily Injury per occurrence/ $50,000 Property Damage per occurrence OR $300,000 Combined Single Limit per occurrenceNote: The choice of Limit B results in a higher premium.$100,000 Bodily Injury per person/ $300,000 Bodily Injury per occurrence/ $50,000 Property Damage per occurrence - Note: Limit C is available only if ALL drivers are between age 22 and 69. Limit C is NOT available if any response makes the risk Standard II; and/or if any response makes the risk PUP Special. Excess UM/UIM is not available if you maintain Limit C. The choice of Limit C results in a higher premium.
NOTICE: ANY PERSON WHO, KNOWINGLY OR WITH INTENT TO DEFRAUD OR TO FACILITATE A FRAUD AGAINST ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR FILES A CLAIM FOR INSURANCE CONTAINING FALSE, DECEPTIVE OR MISLEADING INFORMATION MAY BE GUILTY OF INSURANCE FRAUD. Signature*
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Personal Umbrella Insurance Questionnaire

Applicant Information