Posts Tagged ‘personal umbrella’

Personal Umbrella Quote

Thursday, May 20th, 2010

Plase take a few moments to complete the following information if you would like to obtain a quote.  Please understand, this is not an application.   If coverage is desire, an application will be sent to you.

All information provided is confidential and will be used solely for the purpose of providing a quote for you.

Name
Business Name
Street Address
City and Zip
Phone Number
Alternate Telephone
Fax Number
Email Address
Underwriting Information
Are any aircraft owned, leased, chartered or furnished for regular use?
Do any drivers have mental or physical impairments?
Are any premises, vehicles, watercraft, aircraft used for business?
Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies?
Do you engage in any type of farming operation?
Do you hold any non-remunerative positions?
Any non-owned property exceeding $1,000 in value in your care, custody or control?
Any non-owned business or professional activities included in the primary policies?
Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?
Was any coverage declined, cancelled or non-renewed within the past 5 years?
Any motorcycles, mopeds or all terrain vehicles owned?
Any other business activities conducted from your residence or premises?
Please explain any YES answers from above
Driver 1 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
Occupation
Driver 2 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
Occupation
Driver 3 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
Occupation
Driver 4 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
Occupation
Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)
Driver 1
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 2
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 3
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 4
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Miscellaneous and Claims Information
What is the number of single family dwellings you own?
What is the number of autos you own?
What is the number of recreational vehicles you own?
What is the number of multi-unit buildings you own?
What is the number of vacant property (land) you own?
What is the number of motorcycles you own?
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other: