Umbrella Insurance Application

Address you currently live at*
Street Address Address Line 2 City State ZIP Code
Have you lived here for more than 3 years?*
- Yes
- No
Prior Address*
Street Address Address Line 2 City State ZIP Code

How many motorized vehicles licensed for road use (i.e., motor homes, motorcycles, cars, etc.) are owned, leased, rented, or regularly operated by you or any member of your household?*
Do not count antique, classic or collectible vehicles.
How many residential properties are owned or rented by you or any member of your household?*
1-4 family units are eligible and should be counted as one property. Do not include residential properties that are covered under a Commercial General Liability Policy or other non-personal Premises Liability Policy since they are excluded from coverage.
How many watercraft, between 14 and 45 ft. and with a maximum speed of 50 mph, are owned or regularly operated by you or any member of your household?*
Watercraft exceeding these limitations are excluded from coverage. (Do not count canoes, jet skis, waverunners or other personal watercraft)
How many jet skis, waverunners or other personal watercraft are owned or regularly operated by you or any member of your household?*

What is the total number of drivers?*
Include drivers with a learner's permit.
How many drivers are under the age of 22?*
Include any member of your household with a learner's permit or driver's license.
How many drivers are age 70 or over?*
How many moving violations have all drivers had within the last 3 years?*
(Include DWI/DUI incidents within the last 5 years)
How many at-fault accidents have all drivers in your household had in the last 3 years?*

How many antique, classic and/or collectible vehicles are owned by you or any member of your household?*
How many residential properties owned or rented by you or any member of your household are located outside of the U.S.*
(Including its territories and possessions), Puerto Rico or Canada?
How many acres of timberland and/or land that is farmed, for which the liability coverage is provided by a Homeowners, Farmowners or Farm Comprehensive Personal Liability Policy do you or any member of your household own or lease (including partial ownership)?*

How many drivers have been licensed to drive in the U.S. less than one year, currently have a learner's permit, and/or have a non-U.S. driver's license?*
How many driving incidents have all drivers ages 20-21 and/or age 80 or over had within the last 3 years?*
How many arrests, citations or license suspensions for driving under the influence of alcohol/drugs, driving while intoxicated and/or any other alcohol/drug related incidents have all drivers had in the last 5 years?*

Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving, negligent driving and/or had a driver's license suspended (suspended for other than driving under the influence of alcohol or drugs), revoked or refused in the last 5 years?*
- Yes
- No
Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years?*
- Yes
- No
Do you or any member of your household have an occupation of a professional entertainer, athlete, or media personality, or hold a position as an appointed or elected political figure at the federal or state level, or in a political subdivision lower than the state level where the population within that subdivision exceeds 100,000 people?*
- Yes
- No
Have you or any member of your household had any personal liability or personal auto bodily injury liability claims for which payment by your insurance company exceeded $25,000 in the last 5 years?*
- Yes
- No

Do you and ALL members of your household agree to maintain the MINIMUM REQUIRED LIMITS OF LIABILITY coverage outlined below as a condition of coverage? If applicable*
- Yes
- No

Risk Type, if applicable	Minimum Required Limits of Liability
PRIMARY RESIDENCE ONLY (requires homeowners or comprehensive personal liability)	$300,000 per occurrence
SEASONAL, SECONDARY OR RENTAL PROPERTIESrequires premise's liability or comprehensive personal liability)	$300,000 per occurrence
NOTE: Residential properties that are covered under a commercial or other non-personal premises liability policy are excluded from coverage.
FARMOWNERS OR FARM COMPREHENSIVE PERSONAL LIABILITY	$300,000 per occurrence
UNLICENSED RECREATIONAL VEHICLES (Including snowmobiles, ATVs, golf carts, etc.)	$100,000 Combined Single Limit per occurrence $100,000/$300,000/$25,000
WATERCRAFT (Including boats, personal watercraft, jet skis and canoes)	$300,000 Combined Single Limits -OR- $250,000/$500,000/$100,000 -OR- $300,000/$300,000/$100,000

Please review all of below and choose the limits of insurance coverage you currently have active.
- Limit A
- Limit B
- Limit C

Limit A	Limit B	Limit C
$500,000 Bodily Injury per person/$500,000 Bodily Injury per occurrence/$50,000 Property Damage per occurrence -OR- $500,000 Combined Single Limit per Occurrence	$250,000 Bodily Injury per person/$500,000 Bodily Injury per occurrence/$50,000 Property Damage per occurrence -OR- $300,000 Bodily Injury per person/$300,000 Bodily Injury per occurrence/$50,000 Property Damage per occurrence -OR- $300,000 Combined Single Limit per occurrence	$100,000 Bodily Injury per person/$300,000 Bodily Injury per occurrence/$50,000 Property Damage per occurrence

Please provide everyone in the household with a driver license or a learner's permit*
Full Name Date of Birth Relationship to You Driver License#/Permit # Issue State # of Accidents last 5 years # of Moving violations last 5 years # of DWI/DUI last 5 years

(use the plus sign to add more)