Personal Umbrella

Agency Information

Agency Name:*

Agency Contact's Name:*

Agency Contact's Email Address*

Agency Contact's Phone*

Insured's Information

Insured First & Last Name*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email Address*

Add 2nd Named Insured?*

Yes
No

2nd Named Insured First & Last Name*

2nd Named Insured Mailing Address Same As Above?*

Yes
No

2nd Named Insured Mailing Address*

Street Address Address Line 2 City State ZIP Code

2nd Named Insured Phone*

2nd Named Insured Email Address*

Employment

Employment information is required for any Named Insured on the policy.

Named Insured Occupation*

Named Insured Employer's Name*

Named Insured Employer's Address*

Street Address Address Line 2 City State ZIP Code

2nd Named Insured Occupation*

2nd Named Insured Employer's Name*

2nd Named Insured Employer's Address*

Street Address Address Line 2 City State ZIP Code

Umbrella Coverages

Requested Effective Date*

Policy Amount*

Limits of $6,000,000-$10,000,000 are available as Non-Admitted only

Increased UM - Underlying UM Coverage Must Match Underlying Auto Liability Limits*

ID Theft Coverage*

Personal Cyber Liability*

Any applicant currently insured with RLI or USLI?*

Yes
No

Provide Carrier and Policy Number:*

Automobile Driver Information

List all drivers in household and all operators of vehicles/watercraft

Operator 1: First & Last Name*

Operator 1: Driver's License Number*

Operator 1: State Licensed*

Operator 1: Date Of Birth*

Operator 1: Years Of Driving Experience*

Operator 1: Violations Or Accidents In The Past 5 Years?*

Major Violations
Minor Violations
Accidents
Non-Chargeable Violations
None

Add Operator 2?*

Yes
No

Operator 2: First & Last Name*

Operator 2: Driver's License Number*

Operator 2: State Licensed*

Operator 2: Date Of Birth*

Operator 2: Years Of Driving Experience*

Operator 2: Violations Or Accidents In The Past 5 Years?*

Major Violations
Minor Violations
Accidents
Non-Chargeable Violations
None

Add Operator 3?*

Yes
No

Operator 3: First & Last Name*

Operator 3: Driver's License Number*

Operator 3: State Licensed*

Operator 3: Date Of Birth*

Operator 3: Years Of Driving Experience*

Operator 3: Violations Or Accidents In The Past 5 Years?*

Major Violations
Minor Violations
Accidents
Non-Chargeable Violations
None

Add Operator 4?*

Yes
No

Operator 4: First & Last Name*

Operator 4: Driver's License Number*

Operator 4: State Licensed*

Operator 4: Date Of Birth*

Operator 4: Years Of Driving Experience*

Operator 4: Violations Or Accidents In The Past 5 Years?*

Major Violations
Minor Violations
Accidents
Non-Chargeable Violations
None

Add Operator 5?*

Yes
No

Operator 5: First & Last Name*

Operator 5: Driver's License Number*

Operator 5: State Licensed*

Operator 5: Date Of Birth*

Operator 5: Years Of Driving Experience*

Operator 5: Violations Or Accidents In The Past 5 Years?*

Major Violations
Minor Violations
Accidents
Non-Chargeable Violations
None

Any excluded drivers on the primary policy?*

Yes
No

Explain*

Automobiles

List all owned or leased automobiles, motorhomes, snowmobiles, dune buggies, minibikes, golf carts, etc.

Vehicle 1 Year*

Vehicle 1 Make*

Vehicle 1 Model*

Vehicle 1 VIN*

Vehicle 1 Type*

Vehicle 1 Underlying Carrier*

Vehicle 1 Underlying Liability Limits*

Vehicle 1 Underlying UM/UIM Limits*

Add Vehicle 2?*

Yes
No

Vehicle 2 Year*

Vehicle 2 Make*

Vehicle 2 Model*

Vehicle 2 VIN*

Vehicle 2 Type*

Vehicle 2 Underlying Carrier*

Vehicle 2 Underlying Liability Limits*

Vehicle 2 Underlying UM/UIM Limits*

Add Vehicle 3?*

Yes
No

Vehicle 3 Year*

Vehicle 3 Make*

Vehicle 3 Model*

Vehicle 3 VIN*

Vehicle 3 Type*

Vehicle 3 Underlying Carrier*

Vehicle 3 Underlying Liability Limits*

Vehicle 3 Underlying UM/UIM Limits*

Add Vehicle 4?*

Yes
No

Vehicle 4 Year*

Vehicle 4 Make*

Vehicle 4 Model*

Vehicle 4 VIN*

Vehicle 4 Type*

Vehicle 4 Underlying Carrier*

Vehicle 4 Underlying Liability Limits*

Vehicle 4 Underlying UM/UIM Limits*

Add Vehicle 5?*

Yes
No

Vehicle 5 Year*

Vehicle 5 Make*

Vehicle 5 Model*

Vehicle 5 VIN*

Vehicle 5 Type*

Vehicle 5 Underlying Carrier*

Vehicle 5 Underlying Liability Limits*

Vehicle 5 Underlying UM/UIM Limits*

Watercraft

List all watercraft owned, leased, chartered or furnished for regular use.

Add Watercraft?*

Yes
No

Watercraft 1: Year*

Watercraft 1: Type, Manufacturer & Model*

Watercraft 1: Length (feet)*

Watercraft 1: Horsepower*

Watercraft 1: Max Speed*

Watercraft 1: Underlying Carrier*

Watercraft 1: Underlying Liability Limits*

Add Watercraft 2?*

Yes
No

Watercraft 2: Year*

Watercraft 2: Type, Manufacturer & Model*

Watercraft 2: Length (feet)*

Watercraft 2: Horsepower*

Watercraft 2: Max Speed*

Watercraft 2: Underlying Carrier*

Watercraft 2: Underlying Liability Limits*

Add Watercraft 3?*

Yes
No

Watercraft 3: Year*

Watercraft 3: Type, Manufacturer & Model*

Watercraft 3: Length (feet)*

Watercraft 3: Horsepower*

Watercraft 3: Max Speed*

Watercraft 3: Underlying Carrier*

Watercraft 3: Underlying Liability Limits*

Add Watercraft 4?*

Yes
No

Watercraft 4: Year*

Watercraft 4: Type, Manufacturer & Model*

Watercraft 4: Length (feet)*

Watercraft 4: Horsepower*

Watercraft 4: Max Speed*

Watercraft 4: Underlying Carrier*

Watercraft 4: Underlying Liability Limits*

Add Watercraft 5?*

Yes
No

Watercraft 5: Year*

Watercraft 5: Type, Manufacturer & Model*

Watercraft 5: Length (feet)*

Watercraft 5: Horsepower*

Watercraft 5: Max Speed*

Watercraft 5: Underlying Carrier*

Watercraft 5: Underlying Liability Limits*

Real Estate

List all owned, leased, or occupied residences, buildings, farms, vacant land, etc.

Location 1*

Street Address Address Line 2 City State ZIP Code

Location 1 Number of Units/Acres*

Location 1 Underlying Carrier*

Location 1 Underlying Liability Limit*

Location 1 Occupancy*

Add Location 2?*

Yes
No

Location 2*

Street Address Address Line 2 City State ZIP Code

Location 2 Number of Units/Acres*

Location 2 Underlying Carrier*

Location 2 Underlying Liability Limit*

Location 2 Occupancy*

Add Location 3?*

Yes
No

Location 3*

Street Address Address Line 2 City State ZIP Code

Location 3 Number of Units/Acres*

Location 3 Underlying Carrier*

Location 3 Underlying Liability Limit*

Location 3 Occupancy*

Add Location 4?*

Yes
No

Location 4*

Street Address Address Line 2 City State ZIP Code

Location 4 Number of Units/Acres*

Location 4 Underlying Carrier*

Location 4 Underlying Liability Limit*

Location 4 Occupancy*

Any animals in a listed location's household?*

Yes
No

List breed, bite history, fighting or security training, if applicable.*

Any swimming pools?*

Yes
No

Provide Location Address & specify if fence, diving board and/or slides present*

Any land used for hunting?*

Yes
No

Provide Location Address & Explain*

Are any locations owned by an LLC or Trust?*

Yes
No

Provide Location Address & Explain Ownership*

Are any business activities (including daycare) conducted from your residence or premises (excluded in policy jacket)*

Yes
No

Provide Location Address & Explain Business Activities

General Questions

Has the applicant(s) had any non-automobile claims in the last 5 years?*

Yes
No
N/A - only seeking umbrella over automobile policy

Type of Claim*

Claim Date*

Amount Paid Out*

Explain the claim and if repairs have been made:*

Add a 2nd claim?*

Yes
No

Claim 2: Type of Claim*

Claim 2: Claim Date*

Claim 2: Amount Paid Out*

Claim 2: Explain the claim and if repairs have been made:*

Add a 3rd claim?*

Yes
No

Claim 3: Type of Claim*

Claim 3: Claim Date*

Claim 3: Amount Paid Out*

Claim 3: Explain the claim and if repairs have been made:*

Any applicant considered a high profile risk such as politician, entertainer, professional athlete, etc?

Yes
No

Explain*

Any applicant hold any non-remunerative positions?*

Yes
No

Explain

Any driver with a mental/physical impairment that may affect operation or a motorized vehicle intended for use on land or water? (Such as Dementia, Alzheimer's, Epilepsy or Parkinson's)*

Yes
No

Explain*

Any applicant convicted of insurance fraud or a felony?

Yes
No

Explain*

Any aircraft owned, leased, chartered, or furnished for regular use? (excluded in policy jacket)*

Yes
No

Explain*

Any premises, vehicles (including motorcycles, mopeds, ATVs), watercraft whether owned, hired, leased, or regularly used not covered by primary policies?

Yes
No

Explain*

Any premises, vehicles, watercraft, aircraft used for business?*

Yes
No

Explain*

Does applicant employ any residence employees?*

Yes
No

Explain*

Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?*

Yes
No

Explain*

Any non-owned business and/or professional activities included in the primary policy(ies)?*

Yes
No

Explain*

Was any coverage declined, cancelled, or non-renewed in the last 5 years?*

Yes
No

Explain*

Please provide all underlying declarations pages*

Drop files here or

Max. file size: 16 MB.

Provide any supporting documentation you may have

Please use this option to attach loss runs or any other documents that would be beneficial to the underwriter for quoting purposes.

Drop files here or

Max. file size: 16 MB.

Additional Information or Comments of which company should be aware?

You may be contacted by a commercial underwriter for additional information.

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Personal Umbrella Quote Request

Agency Information

Insured's Information

Employment

Umbrella Coverages

Automobile Driver Information

Automobiles

Watercraft

Real Estate

General Questions

You may be contacted by a commercial underwriter for additional information.