Umbrella Quote

Agent Information

Agency Name *

Agency Code *

Agent First Name *

Agent Last Name *

Agent Email *

Agent Phone Number *

Applicant Information

Insured First Name & Last Name *

Mailing Address *

Country

City

State

Zip code

Requested Effective Date *

Umbrella Coverages

Policy Amount *

Limits of $6,000,000 to $10,000,000 are available on Non-Admitted terms only.

Increased UM - Underlying UM Coverage must match Underlying Auto Liability Limits *

ID Theft Coverage *

Personal Cyber Liability *

Primary Policy Information

Operator Information: List all members of household and all operators of vehicles/watercraft

1. Name *

First & Last

1. Drivers License Number *

1. State *

1. Date of Birth *

1. Explain & advise number of major violations: *

1. Explain & advise number of minor violations: *

1. Explain & advise number of accidents: (note fault) *

1. Explain & advise number of non-chargeable violations: *

Add Operator 2? *

Yes

2. Name *

First & Last

2. Drivers License Number *

2. State *

2. Date of Birth *

2. Explain & advise number of major violations: *

2. Explain & advise number of minor violations: *

2. Explain & advise number of accidents: (note fault) *

2. Explain & advise number of non-chargeable violations: *

Add Operator 3? *

Yes

3. Name *

First & Last

3. Drivers License Number *

3. State *

3. Date of Birth *

3. Explain & advise number of major violations: *

3. Explain & advise number of minor violations: *

3. Explain & advise number of accidents: (note fault) *

3. Explain & advise number of non-chargeable violations: *

Add Operator 4? *

Yes

4. Name *

First & Last

4. Drivers License Number *

4. State *

4. Date of Birth *

4. Explain & advise number of major violations: *

4. Explain & advise number of minor violations: *

4. Explain & advise number of accidents: (note fault) *

4. Explain & advise number of non-chargeable violations: *

Add Operator 5? *

Yes

5. Name *

First & Last

5. Drivers License Number *

5. State *

5. Date of Birth *

5. Explain & advise number of major violations: *

5. Explain & advise number of minor violations: *

5. Explain & advise number of accidents: (note fault) *

5. Explain & advise number of non-chargeable violations: *

Employment

Occupation *

Employers Name *

Employers Address *

Country

City

State

Zip code

Spouse's/Other's Occupation *

Spouse's/Other's Employers Name *

Spouse's/Other's Employers Address *

Country

City

State

Zip code

Real Estate

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

Location 1 *

Country

City

State

Zip code

Number of unites/acres for location 1 *

Underlying Carrier for location 1 *

Underlying limit for location 1 *

Occupancy for location 1 *

Add location 2? *

Yes

Location 2 *

Country

City

State

Zip code

Number of unites/acres for location 2 *

Underlying Carrier for location 2 *

Underlying limit for location 2 *

Occupancy for location 2 *

Add location 3? *

Yes

Location 3 *

Country

City

State

Zip code

Number of unites/acres for location 3 *

Underlying Carrier for location 3 *

Underlying limit for location 3 *

Occupancy for location 3 *

Add location 4? *

Yes

Location 4 *

Country

City

State

Zip code

Number of unites/acres for location 4 *

Underlying Carrier for location 4 *

Underlying limit for location 4 *

Occupancy for location 4 *

Add location 5? *

Yes

Location 5 *

Country

City

State

Zip code

Number of unites/acres for location 5 *

Underlying Carrier for location 5 *

Underlying limit for location 5 *

Occupancy for location 5 *

Automobiles

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

Add Automobiles? *

Yes

Vehicle 1 Year *

Vehicle 1 Make *

Vehicle 1 Model *

Vehicle 1 Vehicle Type *

Vehicle 1 Underlying Carrier *

Vehicle 1 Underlying Liability Limits *

Vehicle 1 Underlying UM/UIM Limits *

Add Vehicle 2? *

Yes

Vehicle 2 Year *

Vehicle 2 Make *

Vehicle 2 Model *

Vehicle 2 Vehicle Type *

Vehicle 2 Underlying Carrier *

Vehicle 2 Underlying Liability Limits *

Vehicle 2 Underlying UM/UIM Limits *

Add Vehicle 3? *

Yes

Vehicle 3 Year *

Vehicle 3 Make *

Vehicle 3 Model *

Vehicle 3 Vehicle Type *

Vehicle 3 Underlying Carrier *

Vehicle 3 Underlying Liability Limits *

Vehicle 3 Underlying UM/UIM Limits *

Add Vehicle 4? *

Yes

Vehicle 4 Year *

Vehicle 4 Make *

Vehicle 4 Model *

Vehicle 4 Vehicle Type *

Vehicle 4 Underlying Carrier *

Vehicle 4 Underlying Liability Limits *

Vehicle 4 Underlying UM/UIM Limits *

Add Vehicle 5? *

Yes

Vehicle 5 Year *

Vehicle 5 Make *

Vehicle 5 Model *

Vehicle 5 Vehicle 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

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

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

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

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

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 *

Claims

Any pending litigation, open or closed claim on ANY primary or excess policy during the last 5 year

Has the applicant had any claims in the last 5 year? *

Yes

Type of claim *

Claim Date *

Amount paid out *

Explain the claim and if repairs have been made *

Add another claim? *

Yes

Type of claim? *

Claim Date? *

Amount paid out? *

Explain the claim and if repairs have been made? *

Add another claim: *

Yes

Type of claim: *

Claim Date: *

Amount paid out: *

Explain the claim and if repairs have been made: *

General Information

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

Yes

1. Explain: *

2. Any driver convicted for any traffic violations? (last 3 years) *

Yes

2. Explain: *

3. Any applicant considered a high profile risk such as politicians, entertainers and professional athletes? (Referral) *

Yes

3. Explain: *

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

Yes

4. Explain: *

5. Any premises, vehicles (including motorcycles, mopeds, ATV’s), watercraft, owned, hired, leased or regularly used, not covered by primary policies? *

Yes

5. Explain: *

6. Do you employ any residence employees? *

Yes

6. Explain: *

7. Any applicant convicted of insurance fraud (ineligible) or a Felony (referral)? *

Yes

7. Explain: *

8. Any driver with mental/physical impairments that may affect operation of a motorized vehicle intended for use on land or water? Such as dementia, Alzheimer's, seizures or Parkinson's. *

Yes

8. Explain: *

9. Are any applicant currently insured with Hudson, RLI, USLI? *

Yes

9. Provide carrier and policy number: *

10. Any locations owned by an LLC or Trust? *

Yes

10. Explain: *

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

Yes

11. Explain: *

12. Was any coverage declined, cancelled non-renewed? (Last 5 years) *

Yes

12. Explain: *

13. Any non-owned business and/professional activities included in the primary policies? *

Yes

13. Explain: *

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

Yes

14. Explain: *

15. Any animals in the household? *

Yes

15. Please list below including breed, bite history, fighting or security training, if applicable. *

16. Any land used for hunting? *

Yes

16. Explain: *

17. Any swimming pools? *

Yes

17. Please specify fenced or unfenced, diving boards or slides *

18. Any excluded drivers on the primary policy? *

Yes

18. Explain: *

19. Any other underwriting information of which Company should be aware? *

Yes

19. Advise: *

20. Do you hold any non-remunerative positions? *

Yes

20. Explain: *

Please provide any supporting documentation you may have:

Document 2

Document 3

Document 4

Any Additional Questions or Comments?

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