Umbrella Coverage

What type of insurance are you looking for today?

PersonalBusiness / CommercialPersonal + Business / Commercial

Personal Umbrella
Personal Umbrella
Feel free to upload any existing ACORD forms or other documents you believe may be relevant.

Cancelof
Contact Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)
Primary Policy Information

Please list your current insurance policies and limits:

	Carrier	Liability Limit	Expiration Data
Auto
Homeowners
Rental Property (if applicable)
Watercraft (if applicable)
Other (e.g., RV, motorcycle)

Household and Vehicle Information
Total Number of Vehicles in Household:
Total Number of Drivers:
List all Licensed Drivers (Name, DOB, License #, State):
Any drivers under age 25?

YesNo
Any drivers with major violations or DUI in the past 5 years?

YesNo
Any youthful operators away at school?

YesNo
Any vehicles titled to business entity?

YesNo
Property and Activities
Number of Residences Owned:
Any Rental Properties? (If yes, number and location)
Any animals on the property? (If yes, please list breed/type)
Any Recreational Vehicles, Boats, or Motorcycles? (If yes, please list types)
Any Swimming Pools, Trampolines, or Home-Base Businesses?

YesNo
Any household employees (nanny, housekeeper, caretaker)?

YesNo
Any farming, rental, or business activities at home?

YesNo
Coverage and Limits
Desired Umbrella Liability Limit:

$ 1 Million$ 2 Million$ 3 Million$ 5 MillionOther
Include Uninsured / Underinsured Motorist Coverage?

YesNo
Include Excess Uninsured Watercraft Coverage?

YesNo
Any cancellations or non-renewals of liability insurance?

YesNo
Please provide details of any prior personal liability claims or lawsuits if any.
Optional Uploads
Feel free to upload any documents you feel are necessary, such as declaration pages for Home and Auto insurance, loss runs, prior umbrella policy.

Cancelof
Please use this space to provide any notes or additional comments/requests.

Business / Commercial Umbrella Insurance
Business / Commercial Umbrella
Feel free to upload any existing ACORD forms or other documents you believe may be relevant.

Cancelof
Business Information
Business Name
Contact Person Name and Title
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Nature of Business
FEIN / Tax ID and Year Established
Underlying Policies

Please list your current insurance policies and limits:

	Carrier	Liability Limit	Expiration Data
General Liability
Auto Liability (Business / Fleet)
Employer's Liability / Workers Comp
Property (if includes liability)
Professional Liability (If any)
Other (Liquor, Garage, Marine, etc.)

Number of Employees:
Annual Gross Revenue: $__
Number of Locations:
Types of Operations:

RetailServiceManufacturingConstructionTransportationOther
If you use any subcontractors, what is the percentage?
Does you business use any of the following: (click all that apply)

Hazardous Operations or MaterialsAircraft, Watercraft, or Rail ExposureEmployees drive company or personal vehicles for business
Loss History & Safety
Click all that apply:

Losses or claims over $25,000 in the past 5 years.Pending or open liability claims.Product recalls or safety violations.Safety / Risk Management Program in place for the business.
Name & Phone Number for Primary Contact for Risk Control:
Coverage Requested
Umbrella Limit Requested:

$1 Million$2 Million$3 Million$5 Million$10 MillionOther
Desired Effective Date: MM/DD/YYYY
Territory:

U.S.A OnlyWorldwide (except U.S.A)Worldwide including U.S.A
Any subsidiaries to include?

YesNo
Any additional insureds to be named? Please provide a list.
Uploads / Attachments
Feel free to upload any documents you feel are necessary, such as declaration pages for current policies, loss runs in the past 3-5 years, safety or risk management documents, or company brochure or website screenshot.

Cancelof
Additional notes or special coverage requests.
Use the space to provide any information you feel is necessary.

Personal Umbrella