Fillable Form 2.: PERSONAL UMBRELLA LIABILITY INSURANCE APPLICATION

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Form 2.: PERSONAL UMBRELLA LIABILITY INSURANCE APPLICATION

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Named Insured may be a maximum of two individuals, provided both individuals reside in the same household.
This policy cannot be issued in the name of an estate, trust or LLC.
* If there are drivers age 70 or over AND an answer to questions 8 or 9 falls under the Standard II or the "PUP Special" column, the risk is not eligible.
**If an answer to questions 1 and/or 2 ONLY is in the "PUP Special" column, up to a $5 million limit is available. A $1 million limit is available if any other
question response is in the "PUP Special" column.
How many drivers are age 70 or over? (Include drivers with a learner’s permit or valid
driver’s license.)
How many moving violations have all drivers had within the last 3 years? (Include
DWI/DUI incidents within the last 5 years.) (See question 27.)
How many at-fault accidents have all drivers had in the last 3 years? (See question
27.)
Primary Residence
Address
City State Zip
Mailing Address (if different from Primary Residence Address)
Address
City State Zip
Carefully read questions 1-9 and circle the correct number. If any question is
unanswered or answered in the "Not Eligible" column, the risk is not eligible.
Preferred Standard
Standard
II*
Not
Eligible
How many motorized vehicles licensed for road use (i.e., motor homes, motorcycles,
cars, etc.) are owned (titled or registered to), leased, rented, or regularly operated by
you or any member of your household? (Do not count antique, classic or
collectible vehicles. See question 10.)
How many Jet Skis, Waverunners or other personal watercraft are owned or regularly
operated by you or any member of your household?
How many drivers are under the age of 22? (Include drivers with a learner’s permit or
valid driver’s license.)
What is the total number of drivers? (Include drivers with a learner's permit or
valid driver's license. See the definition of driver on page 5.)
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 because 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. See question 4.)
PUP
Special**
See page 5 for definitions and question details.
This application can only be used for submissions with a primary residence in Florida.
Please fully complete and print the Application, obtain the insured’s signature and forward it to your Program Administrator for processing.
Any changes made to an answer on this application must be initialed by the applicant.
PERSONAL UMBRELLA LIABILITY INSURANCE APPLICATION
RLI INSURANCE COMPANY
Page 1 of 5
SIGN AND DATE APPLICATION ON PAGE 4
PUP 276FL (10/17)
QUESTIONS 1–9:
1.
2.
4.
3.
5.
6.
7.
8.
9.
Name 1.
2.
Phone Email
0 1 2 3 4 5 6 7 8 9 10 11 or more
0 1 2 3 4 5 6 7 8 9 10 11 or more
0 1 2 3 4 or more
0 1 2 3 4 or more
0 1 2 3 4 5 6 7 8
9 or more
0 1 2 3 4 5 or more
0 1 2 3 4 5 or more
0 1 2 3 4 5 6 7 or more
0 1 2 3 4 or more
Policy Premium
Florida HCF Surcharge &
FIGA Surcharge
Total Annual Premium
Requested Effective Date
Applicant's Brokering Agent Number
Coverage Limit Desired:
$5 Million $3 Million $2 Million $1 Million
$
$
$
Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years?
YES NO
Have you or any member of your household had a liability loss greater than $50,000 in the past 5 years or is there any
open liability claim or lawsuit pending against you or any member of your household?
Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving (with 4 points in
Florida), negligent driving and/or had a driver's license suspended (for reasons other than driving under the influence of
alcohol or drugs), revoked or refused in the last 5 years?
Do you or any member of your household have an occupation of a professional entertainer, athlete, or media personality?
YES NO
YES NO
YES NO
Print the response clearly on the line provided. If the question is unanswered or the response is greater than the maximum number
indicated, the risk is not eligible. PUP Special charge(s) and a $1 million limit apply if any answer to questions 11 through 15 is greater
than 0 (or greater than 640 for question 12.)
PURCHASE
Does any other member of your household or other person residing in your household have a Personal Umbrella policy
with RLI Insurance Company other than this policy?
YES NO
YES NO
Please fully complete and print the Application, obtain the insured’s signature and forward it to your Program Administrator for processing.
How many antique, classic or collectible vehicles are owned (titled or registered to) by you or any member of your household?
(Max. of 25)
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? (Max. of 5)
How many acres of land do you or any member of your household own or lease (including partial ownership)? Max. of 1280
acres. Do not include land that is covered under a Commercial General Liability policy or other non-personal Premises Liability
Policy because they are excluded from coverage.
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? A year or more with a learner's permit does not qualify as a year with a driver's license. (Max. of 8)
How many driving incidents have all drivers ages 21 and under and/or 80 and over had within the last 3 years? (Max. 1 per
driver)
Read and respond by checking "Yes" or "No". If any question is unanswered or checked "Yes", the risk is not eligible.
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? (Max. 1 per household for drivers between ages
22 and 79; 0 per household for drivers under ages 22 and 80 or over.)
Has any one driver had more than 3 moving violations in the last 3 years? (Include DWI/DUI incidents within the last 5
years.)
YES NO
Has any one driver ages 21 and under or 80 and over had more than one driving incident within the past 3 years?
EXCESS UNINSURED/UNDERINSURED MOTORIST (UM/UIM) COVERAGE: Excess UM/UIM coverage is offered for an additional premium.
Required Basic UM/UIM policy limits must be equal to the liability limits for the Required Basic Automobile Liability Policy.
If you elect to purchase this coverage, you are required to accept this coverage in writing and pay the additional premium. If you accept Excess
UM/UIM coverage you must complete and return form PUP257B.
REJECTDo you elect to purchase or reject Excess UM/UIM coverage? (select one)
Submission of a state mandated form supersedes any response to this question.
10.
QUESTIONS 10–15:
QUESTIONS 16–22:
RESPONSE
11.
13.
12.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Page 2 of 5
SIGN AND DATE APPLICATION ON PAGE 4
PUP 276FL (10/17)
QUESTION 23:
Which of the following MINIMUM REQUIRED LIMITS OF AUTOMOBILE LIABILITY do all drivers agree to maintain as a condition of
coverage for all licensed vehicles, that are owned (titled or registered to), leased, rented, operated or acquired during the policy period
by you or any member of your household? If you elect to purchase Excess Uninsured/Underinsured Motorist (UM/UIM) coverage
the Required Basic UM/UIM policy limits must be equal to the liability limits for the required Basic Automobile Liability Policy. You
agree that this condition applies equally to personal use of a vehicle covered under a Commercial Automobile Liability Policy.
$500,000 Bodily Injury per person/
$500,000 Bodily Injury per occurrence/
$50,000 Property Damage per occurrence
Note: Limit C is available ONLY if all drivers in the household are age 22 and over. Limit C is NOT available if there are any drivers age
70 or over; and/or if any response makes the risk Standard II; and/or if any response makes the risk PUP Special.
– OR –
$500,000
combined single limit per
occurrence
If you are unsure what underlying coverage limits you are carrying, or are required to carry, we suggest contacting your local brokering agent.
$250,000 Bodily Injury per person/
$500,000 Bodily Injury per occurrence/
$50,000 Property Damage per occurrence
LIMIT A
Please fully complete and print the Application, obtain the insured’s signature and forward it to your Program Administrator for processing.
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? For those limits that currently do not apply to you or any member of your household,
you must agree to maintain those limits only if they become applicable to you or any member of your household during the
Policy period as a condition of your coverage.
I AGREE TO THE MINIMUM REQUIRED LIMITS OF LIABILITY FOR THE COVERAGES BELOW:
NO
UNLICENSED RECREATIONAL VEHICLES
(Includes snowmobiles, ATVs, golf carts, etc. Required only if you or a member of your household own or
acquire an unlicensed recreational vehicle during the Policy period that is not covered by your homeowners
or personal liability policy for the following limits of liability.)
WATERCRAFT
(Including boats, personal watercraft, Jet Skis and canoes. Required only if you or a member of your
household own or acquire a watercraft during the Policy period that is not covered by your homeowners or
personal liability policy for the following limits of liability.)
QUESTION 25 (You MUST agree to one of the two limits below. If left unanswered, the risk is not eligible):
FARMOWNERS OR FARM COMPREHENSIVE PERSONAL LIABILITY
(Required only if you or any member of your household own a farm which is not covered by your
homeowners policy.)
QUESTION 24 (You must respond by checking “YES” or “NO”):
QUESTION 26 (You MUST agree to one of the three limits below. If left unanswered, the risk is not eligible):
Page 3 of 5
SIGN AND DATE APPLICATION ON PAGE 4
PUP 276FL (10/17)
$100,000 combined single limit
per occurrence
– OR –
$100,000/$300,000/$25,000
$300,000 combined single limits
– OR –
$250,000/$500,000/$100,000
– OR –
$300,000/$300,000/$100,000
Note: The RLI personal umbrella does not provide coverage for watercraft exceeding 45 ft. and/or 50 mph.
This exclusion does not apply to personal watercraft.
$300,000 per occurrence
– OR –
Note: Limit A is ALWAYS REQUIRED if the answer to QUESTION 15 is greater than zero.
$300,000 combined single
limit per occurrence
SELECT ONLY
ONE LIMIT
YES
LIMIT B
$300,000 Bodily Injury per person/
$300,000 Bodily Injury per occurrence/
$50,000 Property Damage per occurrence
– OR –
$100,000 Bodily Injury per person/
$300,000 Bodily Injury per occurrence/
$50,000 Property Damage per occurrence
LIMIT C (The choice of Limit C results in a higher premium. Excess UM/UIM is NOT available if you maintain Limit C.)
$100,000 per occurence (the choice of $100,000 results in a higher premium
and is only available for insured’s with a primary residence in Florida.)
– OR –
PRIMARY RESIDENCE – REQUIRES HOMEOWNERS OR COMPREHENSIVE PERSONAL LIABILITY
SEASONAL, SECONDARY OR RENTAL PROPERTIES REQUIRE PREMISES LIABILITY OR COMPREHENSIVE PERSONAL LIABILITY
$100,000
$300,000
or higher
$300,000 per occurence or higher
Which of the following MINIMUM REQUIRED LIMITS OF LIABILITY do you and ALL members of your household agree to
maintain as a condition of coverage during the Policy period?
Note: If any property identified in question 2 has a liability limit of $100,000 per occurrence, you MUST check the $100,000 box above.
Residential properties that are covered under a commercial or other non-personal premises liability policy are excluded from coverage.
APPLICANT STATEMENT: The information given on this application is true and complete to the best of my knowledge. I understand that any omission
or misstatement of fact in the information given voids the policy. I agree that I will acquire and maintain Minimum Required Limits of Liability for all
additional exposures (drivers, houses, vehicles, watercraft, etc.) if they become applicable during the policy period. The insured's Brokering Agent shall
not have the right to make, alter, modify, or discharge any contract or policy issued on the basis of this Application. I understand that the application and
prepayment of premium must be accepted by RLI Insurance Company.
IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: I understand that as a part of the underwriting procedure, a consumer
report may be obtained or an investigative consumer report may be prepared. Such reports may include information regarding my driving record, credit
history, general reputation, personal characteristics and mode of living. I hereby consent to the preparation of such reports and the disclosure of such
reports to RLI Insurance Company and the producer of record. I understand that these reports will be handled in the strictest confidence, and that
information as to the nature and the scope of these reports will be provided to me upon request.
FRAUD WARNING: Any person who knowingly defrauds any insurance company or other person, files an application for insurance or statement of
claim containing any materially false, incomplete, or misleading information, or conceals information concerning any material fact thereto, commits a
fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil penalties.
NOTE: ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATION MUST BE INITIALED BY THE APPLICANT.
NOTE: THE SAME VERSION DATE MUST APPEAR ON ALL 4 PAGES OF THE APPLICATION.
I UNDERSTAND THIS APPLICATION IS SUBJECT TO UNDERWRITING REVIEW, IS NOT A BINDER AND NO INSURANCE WILL BE IN EFFECT
UNTIL RLI INSURANCE COMPANY ISSUES A POLICY. THE APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT'S ORIGINAL
SIGNATURE.
A PREMIUM CHECK MUST ACCOMPANY THE APPLICATION TO COMPLETE PROCESSING.
Please fully complete and print the Application, obtain the insured’s signature and forward it to your Program Administrator for processing.
Complete the following for all drivers AND members of your household ages 14 and older. Per the definition of driver, also include any other person
who operates a vehicle owned (titled or registered to), leased, rented or regularly operated by you or a member of your household at least 50% or
more of that vehicle's use.
Applicant's Brokering Agent's Signature:
Applicant's Brokering Agency's Name:
Applicant's Brokering Agency's Address:
Applicant's Brokering Agent's License ID #:
Page 4 of 5
SIGN AND DATE THIS PAGE
PUP 276FL (10/17)
QUESTION 27:
Full Name
(First, MI, Last)
Date of
Birth
Licensed
or
Permit?
Y/N
Driver's License
or Permit Number State
Relationship
to Applicant
DWI
or
DUI?
Y/N
Number of
At-Fault
Accidents
(3 yrs)
Number of
Violations 3 yrs
(Incl. DWI/DUI
5 yrs)
If you are applying by Power of Attorney on behalf of the applicant, you must sign your own name followed by “POA”.
SIGN
HERE
SIGN AND DATE
Applicant's Original Signature: Date:
(FL Requirement: This application is in compliance with Section 626.752, Florida Statutes. A copy has been furnished to the applicant and
coverage is Not Bound.)
DEFINITIONS AND QUESTION DETAILS:
Please fully complete and print the Application, obtain the insured’s signature and forward it to your Program Administrator for processing.
• PUP Special exposure charges are added to either the Preferred, Standard or Standard II premium.
• Drivers age 21 and under or age 80 or over may not have any alcohol related incidents. These drivers may have only one
incident.
• The total number of properties allowed is 10. The maximum number of residential properties owned or rented by you or any
member of your household located outside the U.S. (including its territories and possessions), Puerto Rico and Canada is 5.
• The exposure charge for 641 to 1280 acres is a flat charge. It is not a per acre charge.
• Required underlying liability limits for Automobile, Uninsured/Underinsured Motorist (UM/UIM), Property, and Watercraft are
listed on the application. Carefully review these limits and make certain that you and all members of your household are
carrying the proper underlying amount of coverage.
• If you cancel the policy prior to the end of the Policy period, the return premium may be calculated on a basis that is other than
a pro rata basis. The premium returned may be reduced by up to 10% of the pro rata return premium and will be calculated at
the time of cancellation.
DEFINITIONS:
"You", "Your" and "I" means the applicant.
"Member of your household" means your spouse by marriage or civil union; any person related to you by blood or adoption, who
resides with you, even if temporarily away at school; and anyone else who resides with you while in your or a relative's care or
custody.
"Driver" means you and members of your household who operate motor vehicles licensed for road use, plus any other person who
operates a vehicle owned, leased, rented, or regularly operated by you or a member of your household at least 50% or more of that
vehicle's use. Driver includes any person with a learner’s permit or valid driver’s license. Vehicles owned by you or a member of your
household include any vehicles titled to or registered in the name of you or a member of your household.
"Incident(s)" includes any moving violation, at-fault accident and/or traffic arrest, citation or conviction.
"At-Fault Accident" includes any single or multi-car accident chargeable under a primary auto policy, any accident resulting in any
payment for bodily injury or property damage, any single car accident resulting in payment to an insured (unless caused by an animal),
and/or any accident resulting in a citation to you or a member of your household with or without a conviction or final adjudication.
"Antique, classic or collector vehicles" includes private passenger vehicles more than 20 years old, licensed for road use, driven
less than 2,500 miles annually, owned for limited pleasure use, car shows and club events and insured under a Collectors Automobile
Policy.
QUESTION DETAILS:
All Questions: You and all members of your household should be considered when answering any question on this application.
Question 1: Include company vehicles provided for your use, or for use by a member of your household. All vehicles licensed for
road use need to be counted regardless of individual insurance. Full Timers should count their RV as a vehicle and not a residence.
Question 2: Primary residences must have liability coverage under a policy containing Comprehensive Personal Liability (including
Homeowners and Farmowners). Seasonal, secondary or rental properties may have liability coverage under a Comprehensive
Personal Liability or Premises Liability Policy. Do not include residential properties that are covered under a Commercial General
Liability Policy or other non-personal Premises Liability Policy as they are excluded from coverage.
Question 8: Count only moving violations with one ore more points assessed to the driver's license.
Question 11: RLI provides worldwide coverage, provided suit on the merits is brought in the U.S. (including its territories and
possessions), Puerto Rico or Canada.
Page 5 of 5
SIGN AND DATE APPLICATION ON PAGE 4
PUP 276FL (10/17)
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Form 2.: PERSONAL UMBRELLA LIABILITY INSURANCE APPLICATION

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Completed 23 February 2022

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