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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
Required
Last Name
Required
Occupation
Optional
Address of primary residence
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Applicant Type
Required



UNDERLYING LIMITS OF INSURANCE
Underlying Homeowners Personal Liability Limit
Optional
Underlying auto bodily injury liability limit
Optional
Underlying UM/UIM limit on auto policy
Optional
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?
Required

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?
Required

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?
Required

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?
Optional

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

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

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


Maximum Speed?
Optional
Total Horsepower
Optional
Waters Navigated
Optional


Any Paid Crew or Captain?
Optional

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


Maximum Speed
Optional
Total Horsepower
Optional
Waters Navigated
Optional


Any Paid Crew or Captain?
Optional
Underlying limit
Optional
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
Required
License (State, Number)
Optional
Moving Violation Convictions in last 3 years
Optional
Major Moving Violation Convictions in last 3 years
Optional
List At Fault Accidents for Last 3 years?
Optional
Any drug or alcohol related offenses in last 5 years?
Optional

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

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

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

If YES, please explain
Required
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.?
Optional

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?
Optional

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?
Optional

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

5. Are any locations to be included subsidized housing?
Optional

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

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?
Optional

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

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

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

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

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

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

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

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

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?
Optional

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



If Tenant occupied, number of units?
Optional
If farm, number of acres
Optional
Vacant land, number of acres
Optional
Underlying Liability Limit?
Optional
If you own additional properties, please provide above information on an attached sheet.
Optional
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
Optional
Your relationship to the named insured to which this policy applies
Required
Date signed
Optional
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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.

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