PERSONAL UMBRELLA UNDERWRITING QUESTIONS

DO YOU OWN ANY OTHER PROPERTIES THAT ARE NOT INSURED WITH US?*

Yes
No

Please specify*

DO YOU OWN ANY VEHICLES THAT ARE NOT INSURED WITH US?*

Yes
No

Please specify*

DO YOU OWN ANY SECONDARY HOMES OR INVESTMENT PROPERTIES?*

Yes
No

Please specify*

DO YOU OWN ANY RECREATIONAL VEHICLES?*

Yes
No

Please specify*

DO YOU OWN ANY WATERCRAFT?*

Yes
No

Please specify*

ANY DRIVER HAVE A PHYSICAL IMPAIRMENT THAT WOULD AFFECT THE ABILITY TO DRIVE?*

Yes
No

Please specify*

ANY DRIVER UNDERGOING A COURSE OF MEDICAL TREATMENT FOR A PHYSICAL / MENTAL IMPAIRMENT THAT WOULD AFFECT THE ABILITY TO DRIVE?*

Yes
No

Please specify*

OCCUPATIONS*

ANY SWIMMING POOL, SPA OR HOT TUB ON PREMISES?*

Yes
No

Is it fenced?*

Yes
No

Hidden

List*

LOC #	DESCRIPTION	ABOVE GROUND	IN GROUND	APPROVED FENCE	DIVING BOARD	SLIDE	OTHER

ANY RESIDENTIAL EMPLOYEES?*

Yes
No

# EMPLOYEES*

FULL TIME
PART TIME

FULL TIME # EMPLOYEES*

LOC #	INSIDE + OUTSIDE	HRS / WEEK	DUTIES	TOTAL PAYROLL ALL EMPLOYEES ($)

PART TIME # EMPLOYEES*

LOC #	INSIDE + OUTSIDE	HRS / WEEK	DUTIES	TOTAL PAYROLL ALL EMPLOYEES ($)

DO YOU HAVE ANY ANIMALS OR EXOTIC PETS? IF SO WHAT KIND?*

Yes
No

ANIMAL TYPE	BREED	BITE HISTORY (Y/N)

IS THERE A TRAMPOLINE ON THE PREMISES?*

Yes
No

Does it have a net?*

Yes
No

ANY AIRCRAFT OWNED, LEASED, CHARTERED OR FURNISHED FOR REGULAR USE?*

Yes
No

Please explain*

ANY REAL ESTATE, VEHICLE, WATERCRAFT OR AIRCRAFT USED COMMERCIALLY OR FOR BUSINESS PURPOSES?*

Yes
No

Please explain*

ANY REAL ESTATE, VEHICLE, WATERCRAFT OR AIRCRAFT THAT IS OWNED, HIRED, LEASED OR REGULARLY USED, THAT IS NOT COVERED BY PRIMARY POLICIES?*

Yes
No

Please explain*

DO YOU ENGAGE IN ANY TYPE OF FARMING OPERATION?*

Yes
No

Please explain*

DO YOU HOLD ANY NON-COMPENSATED POSITIONS?*

Yes
No

Please explain*

ANY NON-OWNED PROPERTY EXCEEDING $1,000 IN VALUE, IN YOUR CARE, CUSTODY OR CONTROL?*

Yes
No

Please explain*

ANY BUSINESS AND/OR PROFESSIONAL ACTIVITIES INCLUDED IN THE PRIMARY POLICIES?*

Yes
No

Please explain*

DOES ANY PRIMARY POLICY HAVE REDUCED LIMITS OF LIABILITY OR ELIMINATE COVERAGE FOR SPECIFIC EXPOSURES?*

Yes
No

Please explain*

ANY PENDING LITIGATION, COURT PROCEEDINGS OR JUDGEMENTS?*

Yes
No

Please explain*

ANY COVERAGE DECLINED, CANCELLED, OR NON-RENEWED DURING THE LAST FIVE (5) YEARS?*

Yes
No

Please specify*

Applicant Email Address*