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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

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

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

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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Physical: 3440 Blue Springs Road, #503j, Kennesaw, GA 30144
P: (770) 974-0670 | F: (770) 974-8577 |
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