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Commercial Umbrella Liability Insurance Application

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.



General Info
   Name:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
  Email Address:  
Best Time To Contact:
Contact By:

Policy Info
  Transaction Type:  
Proposed Retroactive Date:
Current Retroactive Date:
Limit of Liability: $

Premise Information
Street:
City:
County:
Zip Code
City Limits
Ownership Interest:
Year Built:
Square Footage:
Part Occupied:
Construction Type:
Roof Type:
Monitored Alarm:
Number of Employees
Annual Payroll:
Annual Gross Sales:
Describe Nature of Business:
Please list any subsidiary companies if any in description
Additional Locations:
Enter the information requested above for any additional locations below

Underlying Insurance
List all liability/compensation policies in force to apply as underlying insurance
Type Carrier/Policy
Number
Policy
Effective Date
Policy
Expiration Date
Limits Annual Renewal Premium
Automobile
General Liability
Employers Liability

Additional Underlying General Questions
Please select the option that best applies to the items below.
Check If Approriate:

Aircraft Liability:
Aircraft Passenger Liability
Additional Interests:
Care, Custody, Control:
Employee Benefit Liability:
Foreign Liability/Travel:
Garagekeepers Liability
Incidental Medical Malpractice:
Liquor Liability:
Pollution Liability:
Professional Liability (E&O):
Vendors Liability
Watercraft Liability
Underlying Insurance Coverage Information
include all restrictions; e.g. laser endorsements, discrimination, etc.
Previous Experience:
give details of all liability claims exceeding $10,000 or occurrences that may give arise to claims, during the past 5 years, insured or not.

Additional Exporsures
Please answer the questions below and explain any "Yes" answers in Additional Comments Below
Advertisers Liability
Media Used:
Annual Cost: $
Aircraft Liability
Does Applicant Own/Lease/Operate Aircraft?:
Auto Libility
Are explosives, caustics, flammables or other dangerous cargo hauled?
Are passengers carried for a fee?:
Any units not insured by Underlying Policies?:
Are any vehicles leased or rented to others?
Are hired and non/owned coverages provided?:
Contractors Liability
Is Bridge Dam, or Marine Work Performed?:
Describe Typical Jobs Performed?:
Describe Agreement:
Does applicant own, rent, or use cranes?:
Do subcontractors carry coverages or limits less than applicant?:
Employers Liability
Is applicant self-insured in any state?:
Subject to:
Incidental Malpractice
Is a hospital or first aid facility maintained?:
Are coverages provided for doctors/nurses?:
Pollution Liability
Do current or past products, or their components contain hazardous materials that may require special disposal methods:
Coverages Carried:
Product Liability
Are missiles, engines, guidance systems, frames or any other product use/installed in aircraft?
Are foreign products distributed in U.S.?
Are U.S. Products Sold in Foreign Countries?:
Gross Sales from Past Year:
Protective Liability
Describe Independent Contactors
Watercraft Liability
Does applicant own/lease watercraft:
Apartments/Condominiums/Hotels
Number of Stories:
Number of Units:
Number of Swimming Pools:
Number of Diving Boards:
Additional Comments
If you answered "Yes" to any of the above please explain here:

Vehicles
Number Owned Number Non-Owned Number Leased Avg. Mileage Per Vehicle
Private Passengers
Trucks
Tractors
Buses


Additional Questions
Explain ALL "Yes" Answers in Additional Comments Below
Is the applicant a subsidiary of another entity?:
Is formal safety program in operation?:
Exposure to flammables, explosives?:
Any catastraphe exposures?:
Any other insurance with this company or being submitted?:
Any policy declined, cancelled, non-renewed over last 3 years?:
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring?:
During the last five years, has you been convicted of any degree of the crime of ARSON?:
Any uncorrected fire code violations?:
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?:  
Has business been placed in a trust?:
Additional Comments:
Enter the information about any "YES" answers here

Prior Carrier Information
Carrier:
Insurance Line:
Policy Number:
Policy Type:
Rectroactive Date:
Effective Expiration Date:
Limits  
General Aggregate:
Products:
Personal & Adv Injury:
Each Occurrence:
Fire Damage:
Medical Expense:
Bodily Injury:
Property Damage:
Combined Single Limit:

Loss History 1
Enter any claims or losses (regardless of fault and whether or not insured) or occurrences within the last 5 years.
Date of Occurrence:
Insurance Line:
Type/Description of Occurrence/Claim:
Date of Claim:
Amount Paid:
Amount Reserved:

Loss History 2
Enter any claims or losses (regardless of fault and whether or not insured) or occurrences within the last 5 years.
Date of Occurrence:
Insurance Line:
Type/Description of Occurrence/Claim:
Date of Claim:
Amount Paid:
Amount Reserved:

Additional Information
In the box below, please provide  any additional information  you feel may be necessary  for us to provide you with the best quote possible such as additional operators, coverages engines, etc.
 

Enter text above EXACTLY as it appears:




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