Fillable Excess Personal Umbrella Application (Special Risks)

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Excess Personal Umbrella Application (Special Risks)

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The Excess Personal Umbrella Application (Special Risks) form is 5 pages long and contains:

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  • 4 check-boxes
  • 158 other fields

Country of origin: US
File type: PDF

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Insured Name:
Policy Term Date
From:
To:
Primary Location
Address:
Mailing Address (if different):
APPLICANT INFORMATION
Applicant’s
Occupation:
Underlying Carrier (list in layer order):
Underlying Policy Limit:
Retail Agent_________________________________________
Tel_____________________ Fax_______________________
Co-Applicant’s
Occupation:
EXCESS PERSONAL UMBRELLA APPLICATION Date:
Producer’s Information Retail Agent’s Information
Schedule of Underlying Insurance
REQUESTED LIMIT OF LIABILITY (Each IDENTITY THEFT
occurrence): COVERAGE ($25,000):
YES NO
Producer______________________________________
Address_______________________________________
City
_______________ State_____ Zip__________
E-Mail________________________________________
Address_____________________________________________
City
_______________ State_____ Zip__________
E-Mail______________________________________________
Number of Acres of Vacant Land:
Number of Insured Occupied Residences: Number of Vehicles:
Number of Rentals Units: Number of Watercraft (100 HP or less):
Number of Apartments: Number of Watercraft (Over 100 HP):
Number of Farms:
HUD- XUM APP (12/1
7
) - 1 -
$1,000,000
1
0
0
0
0
0
0
0
1)
Any applicant convicted of
insurance fraud (ineligible) or a
Felony (referral)?
2)
Any applicant considered a high
profile risk such as politicians,
entertainers and professional
athletes? (Referral)
3)
Are any applicants currently
insured with Hudson Insurance
Group? If so, please provide the
policy number(s).
4)
Any driver convicted for any traffic
violations in the last 3 years?
5)
Was any coverage declined,
cancelled non-renewed in the last
5 years?
6)
Are any business activities
(including daycare) conducted from
your residence or premises?
(excluded in policy jacket)
7)
Any animals in the household?
Please list below including breed,
bite history, fighting or security
training, if applicable.
8)
Any excluded drivers on the
primary policy?
9)
Any other underwriting information
of which the Company should be
aware?
10)
Any pending litigation, open or
closed claims exceeding $25,000,
or more than 2 liability claims
during the last 5 years? If Yes,
please provide date, claim status,
paid/reserve amount and
description of the claim.
HUD- XUM APP (12/16) - 2 -
GENERAL INFORMATION: EXPLAIN ALL “YES” RESPONSES IN REMARKS
Yes No Explanation for yes response
EXCESS PERSONAL UMBRELLA APPLICATION
DRIVER SUPPLEMENTAL
OPERATOR INFORMATION: LIST ALL MEMBERS OF HOUSEHOLD AND ALL OPERATORS OF VEHICLES/WATERCRAFT
#
NAME
DRIVER’S
LICENSE NUMBER
STATE
DATE OF
BIRTH
Major
Violations*
(3 Yrs)
Minor
Violations**
(3 Yrs)
At Fault
Accidents
(3 Yrs)
Non-Chargeable
Violations &
Accidents***
(3 Yrs)
1
2
3
4
5
6
7
8
Please list details of activity listed above (Provide claim status, payouts, and reserves for all At Fault Accidents).
DRIVER
DATE OF
VIOLATION/ACCIDENT
DESCRIPTION
*MAJOR VIOLATIONS (including but not limited to): DUI, Hit & Run, Reckless/Negligent Driving, Speeding more than 25 MPH over posted limit (excessive speeding), Evading Police,
Driving on Suspended License, Voluntary/Involuntary Manslaughter, School Bus Violations
**MINOR VIOLATIONS (including but not limited to): Failure to Stop, Failure to Yield, Speeding less than 25 MPH over posted limit, Careless Driving, Following too close, Impeding
Traffic, Illegal Turn, Other Moving Violations
***NON-CHARGEABLE VIOLATIONS (including but not limited to): Cell Phone Violations, Seat Belt Violations, Carpool Violations, Equipment Violations (such as tinted windows or
nonworking head or tail light)
FRAUD NOTICE
To All Prospective Insureds: 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, for the purpose of misleading, conceals information concerning any fact material thereto, may
commit a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties in
many states.
To Prospective Insureds In:
Notice to Colorado Applicants: 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 claiming
with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division
of Insurance within the Department of Regulatory Agencies.
Notice to District of Columbia and Louisiana Applicants: “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.”
Notice to Kansas Applicants: An act committed by 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.
Notice to Maine, Tennessee, Virginia and Washington Applications: 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 and/or denial of insurance benefits.
Notice to Maryland Applicants: 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.
Notice to New Hampshire Applicants: Any person who, with a purpose to injure, defraud or deceive an
insurance company, files a statement of claim containing any false, incomplete or misleading information is
subject to prosecution and punishment for insurance fraud as provided in RSA 638:20.
Notice to New York Applicants: 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,
HUD- XUM APP (12/17) - 4 -
Notice to Florida Applicants: 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.
Notice to Oklahoma Applicants: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a
felony.
commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
$5,000 and the stated value of the claim for each such violation.
I have read the foregoing and agree that it is true and complete to the best of my knowledge and
that this policy, if issued and all renewals thereof are to be issued in reliance upon this information,
unless a change in information is supplied to me. I understand that signing this application does
not bind me to accept this insurance nor does it bind the company to issue a policy to me.
The Insurer is hereby authorized, but not required, to make any investigation and inquiry in
connection with the information, statements and disclosures provided in this Application. The
decision of the Insurer not to make or to limit any investigation or inquiry shall not be deemed a
waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in
this Application in the event the Policy is issued. It is agreed that this Application shall be the basis
of the contract should a policy be issued and it will be attached and become a part of the Policy.
INSURANCE CANNOT BE CONSIDERED FOR BINDING UNLESS THIS APPLICATION IS
SIGNED BY THE APPLICANT:
Applicant’s Signature
X______________________________________Time:________________Date:________________
Agent/Broker Signature
X____________________________________________________Date:_____________________
_
Notice to Pennsylvania Applicants: 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 purposes 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.
HUD- XUM APP (12/17) - 5 -
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Excess Personal Umbrella Application (Special Risks)

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Completed 9 July 2021

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