Commercial Umbrella - King Insurance Services

Agency Name:

Phone:

Agency Contact:

Fax:

E-mail Address:

Applicant Business:

Address:

City:

State:

Zip:

Coverage Limit Requested:

Effective Date:

Expiration Date:

What Underlying Coverages Are We Writing Over:

Auto General Liability Employer Liability

General Liability premium:

Number of Autos:

Workers' Comp. Premium:

Description Of Operations:

Annual Sales:

Annual Payroll:

All Underlying policies are on occurrence forms:

Yes No

All underlying policies are written with carriers rated A- V or higher by A.M. Best:

Yes No

Have there been any losses in the past three years for any of the coverages being provided?:

Yes No

Does the auto fleet exceed 10 Extra Heavy Trucks or 25 total vehicles?:

Yes No

Notes

Commercial Umbrella-Excess Indication - Starstone - AIG