"Our success is not because of the coverage we offer. It's because of the people who write the policies."


Personal Umbrella-Excess Quote

Agency Name: Phone:
Agency Contact: Fax:
E-mail Address:
Applicant Name: DOB:
Location Address:
City: State: Zip:
None of the applicants are the following: • A professional entertainer, public official
• A person appearing regularly on TV or in magazines or in newspapers
• A Division 1 college athlete or coach who appear regularly on TV
If Insured is any of the above, submit for special authorization.
True False
None of the applicant's drivers have had a major violation in the last 5 years. If a major violation has occurred, submit for special authorization.
True False
None of the applicants have had four (4) or more losses or total losses over $25,000 within the past three years, or currently has an open claim. If 4 or more losses have occurred, submit for special authorization.
True False
Please select Primary Carrier type that this policy will be written is excess: All Primary Policies are written with an Admitted insurer rated by A.M. Best B+ (VII)" or higher. We will offer our maximum available limit.
Other: If any of the above do not describe the Primary Insurance Company, we may be able to provide coverage at a lower limit.
Desired Coverage Limit
 

Property/Rentals

Number of Dwelling Units:

Number of Rental Units:

Public Funded Housing Are any of the rentals public funded (includes Sec 8, HUD, Instututional), or used as student housing?
Yes No
Worker or Assisted Living Housing Are any of the rentals migrant or temporary worker housing, or used as adult or child foster care housing or senior assisted living?
Yes No
Security Bars Do any of the rentals have security bars on the windows?
Yes No
Non-Admitted Carrier Are any of the rentals written by a surplus lines/non-admitted carrier or Fair Plan?
Yes No
Please explain any Yes answers here
 

Automobiles

Number of Autos
Number of Motorcycles
Total Drivers in Household or Reqular Users
Number Of Drivers Under 21
Number Of Drivers Over 79
Are Any Drivers Over 89? Yes No
Traffic Violations For Each Driver in the Past Five Years
Notes