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Get a Detailed Quote – Umbrella Insurance
aiinsure
2020-09-03T21:52:37+00:00
Umbrella Insurance Quote
Step Two:
Fill Out The Form Below
Referred To Us By: (Name/Company)
*
Personal Info
Name:
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone:
*
DOB:
*
MM
DD
YYYY
DL#:
Policy Info
Check all that apply:
New
Renewal
Umbrella
Excess
Occurence
Claims Made
Limit of Liability (each occurrence)
*
First dollar defense:
Yes
No
Name and Location of all Subsidiary Companies
(1):
Annual payroll:
Annual gross sales:
Foreign gross sales:
(2):
Annual payroll:
Annual gross sales:
Foreign gross sales:
(3):
Annual payroll:
Annual gross sales:
Foreign gross sales:
Underlying Insurance
(1)Current Auto Carrier:
Policy #:
Eff Date:
Exp Date:
CSL:
BI:
PD:
(2)General Liability Carrier:
Policy #:
Eff Date:
Exp Date:
Each Occ ($):
General Aggr ($):
Damage to rented property ($)
Medical ($):
Annual premium ($):
(3)Employers liability carrier:
Policy #:
Each accident:
Annual premium ($):
Commercial Auto Info
Private Passenger (if any)
Owned:
Yes
No
Non-owned:
Yes
No
Leased:
Yes
No
Property hauled:
How many miles:
Trucks (if any)
Owned:
Yes
No
Non-owned:
Yes
No
Leased:
Yes
No
Light
Medium
Heavy
Ex Heavy
Property hauled:
How many miles:
Buses (if any)
Owned:
Yes
No
Non-owned:
Yes
No
Leased:
Yes
No
Light
Medium
Heavy
Ex Heavy
Property hauled:
How many miles:
Additional Exposures
Advertisers Liability
Media used:
Yes
No
Annual cost ($):
Are services of an advertising agency used:
Yes
No
Covered under agency policy:
Yes
No
Aircraft Liability
Does Applicant own/lease/operate aircraft:
Yes
No
Auto Liability (if any)
Are explosives, caustics, flammable or other dangerous cargo used
Yes
No
Passengers carried for a fee:
Yes
No
Auto leased/rented:
Yes
No
Any units not insured by underlying policies:
Yes
No
Are hired and non/owned cov provided:
Yes
No
Contractors Liability (if any)
Bridge/dam/marine work performed:
Yes
No
Use of cranes:
Yes
No
Employers Liability (if any)
Is applicant self-insured in any state:
Yes
No
Incidental Malpractice Liability (if any)
Hospital/first aid facility maintained:
Yes
No
Coverage provided for doctors/nurses:
Yes
No
# of Doctors
Please enter a number from
0
to
99
.
# of Nurses
Please enter a number from
1
to
99
.
EPA #:
Pollutions Liability (if any)
Missiles/engines/guidance/frames or other products used/installed:
Yes
No
Foreign Oper/Foreign prod dist (USA)/prod sold (foreign countries):
Yes
No
Liability loss in past 3 yrs:
Yes
No
Gross sales (last 3 yrs):
Water Craft Liability (if any)
Liability loss in past 3 yrs:
Yes
No
# Owned:
Length:
Horsepower:
Apartments/Condominiums/Hotels/Motels (if any)
# of Stores:
# of Units:
# of Pools:
# of Diving Boards:
Special Instructions (if any)
Document Upload (if any)
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