Umbrella Insurance Application Quote Step 1 of 14 7% Name Email Phone Address you currently live at?Have you lived here for more than 3 years? Yes No Previous Address Umbrella Coverage Limit Desired 1 Million 2 Million 3 Million 4 Million 5 Million How many motorized vehicles licensed for road use (i.e., motor homes, motorcycles, cars, etc.) are owned, leased, rented, or regularly operated by you or any member of your household? Do not count antique, classic or collectible vehicles.How many residential properties are owned or rented by you or any member of your household? 1-4 family units are eligible and should be counted as one property. Do not include residential properties that are covered under a Commercial General Liability Policy or other non-personal Premises Liability Policy since they are excluded from coverage. How many watercraft, between 14 and 45 ft. and with a maximum speed of 50 mph, are owned or regularly operated by you or any member of your household? 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 regularly operated by you or any member of your household? What is the total number of drivers? Include drivers with a learner's permit. How many drivers are under the age of 22? Include any member of your household with a learner's permit or driver's license. How many drivers are age 70 or over? 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 in your household had in the last 3 years? How many antique, classic and/or collectible vehicles are owned by you or any member of your household? How many residential properties owned or rented by you or any member of your household are located outside of the U.S. (Including its territories and possessions), Puerto Rico or Canada? How many acres of timberland and/or land that is farmed, for which the liability coverage is provided by a Homeowners, Farmowners or Farm Comprehensive Personal Liability Policy do you or any member of your household own or lease (including partial ownership)? 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 a non-U.S. driver's license? How many arrests, citations or license suspensions for driving under the influence of alcohol/drugs, driving while intoxicated and/or any other alcohol/drug related incidents have all drivers had in the last 5 years? Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving, negligent driving and/or had a driver's license suspended (suspended for other than driving under the influence of alcohol or drugs), revoked or refused in the last 5 years? Yes No Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years? Yes No Do you or any member of your household have an occupation of a professional entertainer, athlete, or media personality, or hold a position as an appointed or elected political figure at the federal or state level, or in a political subdivision lower than the state level where the population within that subdivision exceeds 100,000 people? Yes No Have you or any member of your household had any personal liability or personal auto bodily injury liability claims for which payment by your insurance company exceeded $25,000 in the last 5 years? Yes No Does any other member of your household or other person residing in your household have a Personal Umbrella policy that will be active along with this application? Yes No Do you or any member of your household own (including partial ownership) 6 or more residential properties rented to others that are not occupied in whole or in part at any time by you or any member of your household? Yes No 1-4 family units are eligible and should be counted as one property. Has any one driver had more than 3 moving violations in the last 3 years? Yes No (Include DWI/DUI incidents within the last 5 years) Do you elect to purchase or reject Excess UM/UIM coverage? Purchase Reject UM/UIM coverage is insurance that pays for your injuries from an accident caused by the owner or operator of an uninsured or underinsured vehicle. Excess UM/UIM from a personal umbrella policy pays over the auto policy’s UM/UIM limits have been exhausted. UM/UIM coverage comes into play when you are involved in an accident and the person who caused it either doesn’t have any insurance or doesn’t have enough insurance to pay for your injuries. It would also come into play if you were the victim of a hit-and-run (in a vehicle, on a bike, or as a pedestrian), leaving you with nobody’s insurance policy to collect against...making it an “uninsured” motorist claim. Do you and ALL members of your household agree to maintain the MINIMUM REQUIRED LIMITS OF LIABILITY coverage outlined below as a condition of coverage? If applicable Yes No Risk Type, if applicable Minimum Required Limits of Liability PRIMARY RESIDENCE ONLY (requires homeowners or comprehensive personal liability) $300,000 per occurrence SEASONAL, SECONDARY OR RENTAL PROPERTIESrequires premise's liability or comprehensive personal liability) $300,000 per occurrence NOTE: Residential properties that are covered under a commercial or other non-personal premises liability policy are excluded from coverage. FARMOWNERS OR FARM COMPREHENSIVE PERSONAL LIABILITY $300,000 per occurrence UNLICENSED RECREATIONAL VEHICLES (Including snowmobiles, ATVs, golf carts, etc.) $100,000 Combined Single Limit per occurrence $100,000/$300,000/$25,000 WATERCRAFT (Including boats, personal watercraft, jet skis and canoes) $300,000 Combined Single Limits -OR- $250,000/$500,000/$100,000 -OR- $300,000/$300,000/$100,000 Please review all of below and choose the limits of insurance coverage you currently have active. Limit A Limit B Limit C Limit A Limit B Limit C $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 occurrence $100,000 Bodily Injury per person/$300,000 Bodily Injury per occurrence/$50,000 Property Damage per occurrence Please provide everyone in the household with a driver license or a learner's permitFull NameDate of BirthRelationship To YouDriver License## of Accidents last 5 years# of Moving violations# of DWI/DUI last 5 years When do you need the insurance to start?DDMMYYYY Any special concerns or questions? Please ask here
