Personal Umbrella

CONTACT INFORMATION
First Name Required
Last Name Required
Occupation Optional
Address of primary residence Required
City Required
State Required	AL GA NC SC TN
ZIP / Postal Code Required
Primary Phone Number Required
E-Mail Address Required
Applicant Type Required	Individual(s)Trust Limited liability companyLimited liability partnership Limited partnershipEstate
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	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? Required	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? Required	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? Optional	Yes No
Does the applicant own or lease any location used for Farm or Ranch operations? Optional	Yes No
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	Yes No
If YES, please complete the following questions regarding watercraft Optional
Watercraft 1
Year Optional
Make and Model Optional
Length Optional
Type of Watercraft Optional	Sailboat Powerboat Jet Ski / Wave Runner
Maximum Speed? Optional
Total Horsepower Optional
Waters Navigated Optional	Inland U.S. Coastal U.S. International Waters
Any Paid Crew or Captain? Optional	Yes No
Underlying limit? Optional
Watercraft 2
Year Optional
Make and Model Optional
Length Optional
Watercraft type Optional	Sailboat Powerboat Jet Ski / Wave Runner
Maximum Speed Optional
Total Horsepower Optional
Waters Navigated Optional	Inland U.S. Coastal U.S. International Waters
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	Yes No
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	Yes No
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	Yes No
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	Yes No
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	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? Optional	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? Optional	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? Optional	Yes No
5. Are any locations to be included subsidized housing? Optional	Yes No
6. Is there a pool at any location that is either unfenced or has a diving board or waterslide? Optional	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? Optional	Yes No
8. Are any locations leased to others for hunting, fishing or other sporting or recreational purposes? Optional	Yes No
9. Does the applicant or any resident of the applicant's household own any exotic pets? Optional	Yes No
10. Is there a dog exclusion on any primary homeowners or comprehensive personal liability policy? Optional	Yes No
11. Is there an animal exclusion on any primary homeowners or comprehensive personal liability policy? Optional	Yes No
12. Are the minimum underlying limits for automobiles covered completely by a business auto or garage policy? Optional	Yes No
13. Is any of the required underlying insurance provided by a commercial general liability policy or coverage form? Optional	Yes No
14. Does any household operator have any restriction on his/her drivers license other than glasses or corrective lenses? Optional	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? Optional	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? Optional	Yes No
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	Owner Occupied Tenant Occupied Farm Vacant Land
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
For Security of your personal information, enter code and press submit.
Submission Validation Required	Enter the Validation Code from above.

Important Notice
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