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Home > Personal Umbrella > Personal Umbrella
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Personal Umbrella



Call or Submit the Below Quick Form
      

        770-974-0670  Office  9am to 5pm

  • Multiple Carriers Will Compete
  • We'll Contact Same Business Day
  • DWard Insurance since 1988

Our Highly Rated Carriers:

Hartford * Auto Owners * Travelers * Safeco * Progressive * Utica * Main St * ASI * US Liability * Mercury * AmTrust *



CONTACT INFORMATION
First Name *
Last Name *
Occupation
Address of primary residence *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Applicant Type *





UNDERLYING LIMITS OF INSURANCE
Underlying Homeowners Personal Liability Limit
Underlying auto bodily injury liability limit
Underlying UM/UIM limit on auto policy
GENERAL QUESTIONS
Does the applicant or any resident of the applicant's household currently or have they at any time had an occupation as an elected or appointed federal or state political figure? *

Does the applicant or any resident of the applicant's household currently or have they at any time had an occupation as a professional athlete or coach? *

Does the applicant or any resident of the applicant's household currently or have they at any time had an occupation as an entertainer or media personality? *

Does the applicant or any resident of the applicant's household currently or have they at any time had an occupation as a senior executive or officer of a publicly traded company?

Does the applicant own or lease any location used for Farm or Ranch operations?

In addition to your primary residence, please enter the number of owner occupied secondary residences
If applicable, enter the number of 1-4 family residential units rented to others (Duplex = 2 units)
How many Automobile or Motor Homes are owned or furnished for the regular use of all operators in the household?
How many Motorcycles, scooters, or other vehicles with less than four wheels and licensed for road use are owned or furnished for the regular use of all operators in the household?
How many recreational vehicles (vehicles not licensed for road use) are there in the household?
Any watercraft?

If YES, please complete the following questions regarding watercraft
Watercraft 1
Year
Make and Model
Length
Type of Watercraft


Maximum Speed?
Total Horsepower
Waters Navigated


Any Paid Crew or Captain?

Underlying limit?
Watercraft 2
Year
Make and Model
Length
Watercraft type


Maximum Speed
Total Horsepower
Waters Navigated


Any Paid Crew or Captain?
Underlying limit
OPERATOR INFORMATION (Automobiles, Recreational Vehicles, Watercraft)
Please list all members of the applicants household age 14 or older, and all operators of Automobiles, Motorcycles, Watercraft and Recreational Vehicles regardless if licensed
Driver 1
Date of Birth for Driver #1 *
License (State, Number)
Moving Violation Convictions in last 3 years
Major Moving Violation Convictions in last 3 years
List At Fault Accidents for Last 3 years?
Any drug or alcohol related offenses in last 5 years?

If YES, please explain
Driver 2 License Number
Driver 2 Legal Name as appears on License
License (State, Number)
Moving Violation Convictions in last 3 years
Major Moving Violation Convictions in last 3 years
List At Fault Accidents for Last 3 years?
Any drug or alcohol related offenses in last 5 years?

If YES, please explain *
Driver 3 License Number
Driver 3 Name as appears on License
License (State, Number)
Moving Violation Convictions in last 3 years
Major Moving Violation Convictions in last 3 years
List At Fault Accidents for Last 3 years?
Any drug or alcohol related offenses in last 5 years?

If YES, please explain *
Driver 4 License Number
Driver 4 Date of Birth
License (State, Number)
Moving Violation Convictions in last 3 years
Major Moving Violation Convictions in last 3 years
List At Fault Accidents for Last 3 years?
Any drug or alcohol related offenses in last 5 years?

If YES, please explain *
ELIGIBILITY QUESTIONS
1. Does the applicant or any member of the applicant's household currently have any active policies with the United States Liability Insurance Co., Mt. Vernon Fire Insurance Co., or U.S. Underwriters Insurance Co.?

2. Has the applicant or any resident of the applicant's household been convicted of or plead guilty to a felony in the past five years?

3. Hs the applicant or any resident of the applicant's household had a liability loss greater than $50,000 in the past five years or is there an open liability claim or lawsuit pending against them?

4. Are any locations used as rooming houses, student housing other than a college dormitory room, assisted living facilities or group home facilities?

5. Are any locations to be included subsidized housing?

6. Is there a pool at any location that is either unfenced or has a diving board or waterslide?

7. Does the applicant or any resident of the applicant's household operate any business or conduct any professional activities that are covered by primary policies at any location to be covered?

8. Are any locations leased to others for hunting, fishing or other sporting or recreational purposes?

9. Does the applicant or any resident of the applicant's household own any exotic pets?

10. Is there a dog exclusion on any primary homeowners or comprehensive personal liability policy?

11. Is there an animal exclusion on any primary homeowners or comprehensive personal liability policy?

12. Are the minimum underlying limits for automobiles covered completely by a business auto or garage policy?

13. Is any of the required underlying insurance provided by a commercial general liability policy or coverage form?

14. Does any household operator have any restriction on his/her drivers license other than glasses or corrective lenses?

15. Do any of the Required Underlying Insurance policies contain sublimits, have reduced limits of liability, or exclude coverage for specific individuals or exposures?

16. Is there currently, or during the next 12 months will there be, any construction, renovation, or demolition at any residential 1-4 family residence orcondominium owned by or rented to the applicant?

For any YES answer to above questions, please provide explanation
RESIDENTIAL PROPERTIES including Rental Units, Apartments, Vacant Land & Farms
Location/address of primary residence
Number of Units
Underlying Liability Limit
Location/address of secondary property
Type of property?



If Tenant occupied, number of units?
If farm, number of acres
Vacant land, number of acres
Underlying Liability Limit?
If you own additional properties, please provide above information on an attached sheet.
The undersigned declares that he/she has read the responses set out in the Personal Umbrella Application and that such responses/statements are true and accurate to the best of his/her knowledge and belief.
Typing your name here represents your valid signature
Your relationship to the named insured to which this policy applies *
Date signed
For Security of your personal information, enter code and press submit.
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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Mailing: 1720 Mars Hill Rd #8-185, Acworth, GA 30101
Physical: 3440 Blue Springs Road, #503j, Kennesaw, GA 30144

P: (770) 974-0670 | F: (770) 974-8577 |
E: dward@dwardins.com

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