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Excess Auto Liability (RT Specialty)

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PLEASE COMPLETE ALL SECTIONS OF THIS APPLICATIONS.
Excess Auto 10/13
page 1 of 4
Excess Auto Liability
USLI.COM
888-523-5545
1. Name of Applicant: _____________________________________________________________________________________________
2. Profession/ Occupation: Applicant: _____________________________________ Spouse: _________________________________
3. E-mail Address: _______________________________________________________________________________________________
4. Has the applicant or any member of the household been employed as any of the following:
Professional Athlete; Entertainer; Media personality; Reporter; Author; Journalist; Coach in the NBA,
NFL, MLB, NHL, or in College Division I Football or Basketball; Owner of a Professional sports team;
CEO of a Fortune 500 company, or Director or Producer with major television or motion
picture credits? Is any individual an elected or appointed public official at the State or Federal level,
or a generally recognizable public figure? Yes No
5. Mailing Address: _______________________________________________________________________________________________
6. Primary limits of insurance: ________________________________ Excess limits requested: _______________________________
7. Is this a buffer layer to meet our Umbrella requirements? Yes No
8. Has the applicant or any resident of the applicant’s household been convicted of or
plead guilty to a felony in the past 5 years? Yes No
9. Do any underlying policies contain exclusions or restrictions of standard coverage? Yes No
10. Please explain any Yes response: ________________________________________________________________________________
___________________________________________________________________________________________________________
11. List all drivers in the household and anyone else who would regularly drive one of these vehicles
Driver Information 3 Years Experience 5 Years
Name of Driver Marital Status License Number State DOB # Moving
Violations
At Fault #
Accidents
# DUI’s
12. What type of Excess Coverage is the applicant requesting?
Excess Personal Auto Liability - Complete Section I
Excess Watercraft Liability - Complete Section II
Section I. ELIGIBILITY - Excess Personal Auto Liability
List all vehicle information below
Year Make Model Primary Carrier Policy Number Garage Location
13. Does any driver in the household have any mental or physical impairment which would affect their ability to operate
an automobile? Yes No
14. Are the Minimum Underlying Limits for automobiles covered completely by a business auto or garage policy? Yes No
15. Any driver(s) currently excluded under the Primary Auto Policy? Yes No
16. Is there anyone in the household who has a drivers license (active or suspended) who will not be
driving the listed vehicle(s)? Yes No
17. Are there any other vehicles in the household which are not to be covered by this policy? Yes No
Submit Application
page 2 of 4
FRAUD STATEMENTS
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy
only if the misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance
of the risk, or to the hazard assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have
issued a policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts
had been made known to the insurer as required either by the application for the policy or otherwise.
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or
misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance
within the department of regulatory agencies.
District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose
of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided by the applicant.
Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or
an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Florida Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior
coverage may be available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under
the Florida Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the
admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act
with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under
Florida and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known
as “vicariously assessed punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant
as a result of this Application and such Policy provides coverage for punitive damages, I understand and acknowledge that the coverage
for Claims brought in the State of Florida and Illinois is limited to “vicariously assessed punitive damages” and that there is no coverage for
directly assessed punitive damages.
Kansas Fraud Statement: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with
knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as
part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or
a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to
contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning
any fact material thereto may be guilty of a crime and may be subject to fines and confinement in prison.
Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime.
Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to
the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or
incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the
contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of
incidents, occurrences or alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on
the declarations. This policy shall cover only those claims made against an insured while the policy remains in effect for incidents reported
during the Policy Period or any subsequent renewal of this Policy or any extended reporting period and all coverage under the policy
ceases upon termination of the policy except for the automatic extended reporting period coverage unless the insured purchases additional
extend reporting period coverage. The policy includes an automatic 60 day extended claims reporting period following the termination of
this policy. The Insured may purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36
months following the termination of this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period.
During the first several years of a claims-made relationship, claims-made rates are comparatively lower than occurrence rates. The insured
can expect substantial annual premium increases independent overall rate increases until the claims-made relationship has matured.
Excess Auto 10/13
page 3 of 4
North Dakota Fraud Statement: Notice to North Dakota applicants – Any person who knowingly and with the intent to defraud and
insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or
conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime and shall also be subject to a civil penalty.
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Ohio Notice: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the
company are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind
this policy, or any coverage provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the
statements made in the insurance applications are incorporated into, and shall form part of, this policy. I understand that any material
misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or
provide the company the right to rescind it.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud
against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.
Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive
Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which
allows punitive or exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional
location(s) of the Named Insured, outside the state of Utah, for which coverage is sought under the same policy.
Vermont Fraud Statement: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance may be subject to fines and confinement in prison.
Virginia Notice: This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You have
an option to purchase a separate limit of liability for the extended reporting period. If you do not elect this option, the limit of liability for the
extended reporting period shall be part of the and not in addition to limit specified in the declarations. If you have any questions regarding
the cost of an extended reporting period, please contact your insurance company or your insurance agent. Statements in the application
shall be deemed the insured’s representations. A statement made in the application or in any affidavit made before or after a loss under the
policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed
and was untrue.
Virginia Fraud Statement: Any person who knowingly and with intent to defraud an insurer, submits an Application for insurance or files a
claim containing a false or deceptive statement is guilty of insurance fraud.
Utah Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Washington Fraud Statement: Any person, who, knowing it to be such:
(1) Presents, or causes to be presented, a false or fraudulent claim or any proof in support of such a claim, for the payment
of a Loss under a contract of insurance; or
(2) Prepares, makes, or subscribes any false or fraudulent account, certificate, affidavit, or proof of Loss, or other document
or writing, with intent that it be presented or used in support of such a claim, is guilty of a gross misdemeanor, or if such claim
is in excess of one thousand five hundred dollars, of a class C felony.
Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name: _______________________________________________ License#: __________________________________
Agent’s signature: _________________________________________ Main agency phone number ___________________________
(Required in New Hampshire)
Agency mailing address: _______________________________________________________________________________________
City: _______________________________State: _________________________ Zip: ______________________
Excess Auto 10/13
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page 4 of 4
I acknowledge that the information provided in this application is material to acceptance of the risk and the issuance of the requested
policy by Company. I represent that the information provided in this application is true and correct in all matters. I agree that any claim,
incident, occurrence, event or material change in the Applicant’s operation taking place between the date of this Application was signed
and the effective date of the insurance policy applied for which would render inaccurate, untrue or incomplete, any information provided
in this Application, will immediately be reported in writing to the Company and the Company may withdraw or modify any outstanding
quotations and/or void any authorization or agreement to bind the insurance. Company may, but is not required, to make investigation
of the information provided in the Application. A decision by the Company not to make or to limit such investigation does not constitute a
waiver or estoppel of Company’s rights.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Signature: _____________________________________________________________________________________________________
(Chairperson of the Board, Managing Member, President or Executive Director)
Title: _______________________________________________________ Date: __________________________________________
Excess Auto 10/13
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Excess Auto Liability (RT Specialty)

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Completed 13 December 2020

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