Personal Umbrella

CONTACT INFORMATION

First Name *

Last Name *

Occupation

Address of primary residence *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Applicant Type *

Individual(s)
Trust
Limited liability company
Limited liability partnership
Limited partnership
Estate

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? *

Yes
No

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? *

Yes
No

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? *

Yes
No

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?

Yes
No

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

Yes
No

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?

Yes
No

If YES, please complete the following questions regarding watercraft

Watercraft 1

Year

Make and Model

Length

Type of Watercraft

Sailboat
Powerboat
Jet Ski / Wave Runner

Maximum Speed?

Total Horsepower

Waters Navigated

Inland U.S.
Coastal U.S.
International Waters

Any Paid Crew or Captain?

Yes
No

Underlying limit?

Watercraft 2

Year

Make and Model

Length

Watercraft type

Sailboat
Powerboat
Jet Ski / Wave Runner

Maximum Speed

Total Horsepower

Waters Navigated

Inland U.S.
Coastal U.S.
International Waters

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?

Yes
No

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?

Yes
No

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?

Yes
No

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?

Yes
No

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.?

Yes
No

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?

Yes
No

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?

Yes
No

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

Yes
No

5. Are any locations to be included subsidized housing?

Yes
No

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

Yes
No

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?

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

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?

Yes
No

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?

Owner Occupied
Tenant Occupied
Farm
Vacant Land

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.

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Umbrella

Personal Umbrella

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770-974-0670

Resources

Contact Us

Auto & Home

Life & Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Personal Umbrella

Contact Us Today! 770-974-0670

Resources

Contact Us

Auto
&
Home

Life
& Disability

Contact Us Today!
770-974-0670