Fillable Personal Umbrella App Fillable (Colonial General Insurance Agency, Inc)

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Personal Umbrella App Fillable (Colonial General Insurance Agency, Inc)

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Page 1
P.O.
Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(480) 991-7889 WATS (800) 848-8860 FAX (480) 948-1394
P.O.
Box 571770, Murray, UT 84157-1770
5373 S. Green St., Suite 525, Murray, UT 84123
(801) 290-1144 WATS (800) 594-8900 FAX (801) 290-1160
Primary Applicant: _____________________ Agent No: ______________________
Primary Residence: _____________________ Agent Name: ______________________
_____________________
Agent Mailing ______________________
Mailing Address: _____________________ Address: ______________________
_____________________
REQUESTED EFFECTIVE DATE: ________ TO _________ Renewal Of Policy No:_______________
Requested Limit: $1 million $2 million $3million $4 million $5 million
RATING INFORMATION:
1. List ALL primary & secondary (vacation) homes:
# of
Address, City, State, Zip Code Occupancy Pool? Fenced Acres?
1. ______________________________ Primary Yes No Yes No ______
2. ______________________________ Secondary Yes No Yes No ______
3. ______________________________ Secondary Yes No Yes No ______
4. ______________________________ Secondary Yes No Yes No ______
2. List Liability on ALL primary and secondary homes owned.
Carrier: Policy #: Limit:
1. ______________________________ __________________ __________________
2. ______________________________ __________________ __________________
3. ______________________________ __________________ __________________
4. ______________________________ __________________ __________________
Personal Umbrella Application
Page 2
3. List ALL licensed automobiles; i.e. private passenger, motor homes, pickups, motorcycles, ATV’s, RV’s,
snowmobiles, travel trailers, horse trailers, any hauling trailer licensed for the road; owned by, leased,
furnished to, or available for your regular use including corporate owned vehicles.
Year Make Model Type Company Car?
1. _____________ _________ _________ _________ Yes No
2. _____________ _________ _________ _________ Yes No
3. _____________ _________ _________ _________ Yes No
4. _____________ _________ _________ _________ Yes No
5. _____________ _________ _________ _________ Yes No
6. _____________ _________ _________ _________ Yes No
7. _____________ _________ _________ _________ Yes No
4. List the following required underlying policy information. If any of this section is left blank, we will not
be able to consider your application.
Automobile: Does your policy have limits of at least $250,000 each person, $500,000 or greater each
accident for Bodily Injury and at least $100,000 for Property Damage or $500,000 or greater for a
Combined Single Limit? ………………………………………………………………… Yes No
Do company provided vehicles have Drive Other Car coverage for all drivers………… Yes No
Do you and all members of your household agree to maintain Uninsured and Underinsured Motorist limits
equal to the Bodily Injury limit if coverage is elected (where applicable)?…………….. Yes No
(*Include company provided insurance and/or Drive Other Car Coverage)
Insuring Company Policy Number Limits of Liability
1. _______________________ _________________ ____________________
2. _______________________ _________________ ____________________
3. _______________________ _________________ ____________________
4. _______________________ _________________ ____________________
5. _______________________ _________________ ____________________
6. _______________________ _________________ ____________________
7. _______________________ _________________ ____________________
Page 3
5. A. List ALL drivers including anyone who may be driving within the next year. (MVR’s required every 2
years.)
Drivers
Last Name First Name MI DOB License No. State Relationship Occupation
1._____________ __________ ____ _________ ___________ _____ __________ ____________
2._____________ __________ ____ _________ ___________ _____ __________ ____________
3._____________ __________ ____ _________ ___________ _____ __________ ____________
4._____________ __________ ____ _________ ___________ _____ __________ ____________
5._____________ __________ ____ _________ ___________ _____ __________ ____________
B. Describe all violations, motor vehicle accidents or tickets for ALL operators during the past 36 months.
Last Name First Name Date of Description Amount
Violation Of Violation Paid/Reserved
1._____________ __________ ________ ________________________________ __________
2._____________ __________ ________ ________________________________ __________
3._____________ __________ ________ ________________________________ __________
4._____________ __________ ________ ________________________________ __________
5._____________ __________ ________ ________________________________ __________
C. Have you or any driver in your household ever been cited, ticketed, or convicted of driving under the
influence of alcohol or drugs?…………………………………………………………………….. Yes No
If Yes, please explain:___________________________________________________________
_____________________________________________________________________________
D. Have you or any driver in your household every had their driver’s license suspended, revoked
or refused?………………………………………………………………………………………… Yes No
If Yes, please explain:___________________________________________________________
_____________________________________________________________________________
E. Have you or any driver in your household ever been cited, ticketed, or convicted of reckless
driving, hit and run, or vehicular homicide?……………………………………………………… Yes No
If Yes, please explain:___________________________________________________________
_____________________________________________________________________________
F. Does any driver have any mental or physical conditions that may affect their driving ability?… Yes No
If Yes, please explain:___________________________________________________________
_____________________________________________________________________________
Page 4
G. Does your Personal Liability policy include Personal Injury coverage?…………………….. Yes No
If Yes, please explain:___________________________________________________________
_____________________________________________________________________________
H. Do you or any member of your household own any animals or exotic pets?…………………. Yes No
If Yes, please explain:___________________________________________________________
_____________________________________________________________________________
6. List all watercraft owned, rented or operated by members of your household. (Include any jet skis,
Seadoos, etc.)
Inboard,
Inboard/Outboard
Year Make or Outboard HP Maximum Speed Length
1. _____________ _________ _________ _________ ___________ _________
2. _____________ _________ _________ _________ ___________ _________
3. _____________ _________ _________ _________ ___________ _________
4. _____________ _________ _________ _________ ___________ _________
5. _____________ _________ _________ _________ ___________ _________
6. _____________ _________ _________ _________ ___________ _________
7. _____________ _________ _________ _________ ___________ _________
Insuring Company Policy Number Limits of Liability
1. _______________________ _________________ ____________________
2. _______________________ _________________ ____________________
3. _______________________ _________________ ____________________
4. _______________________ _________________ ____________________
5. _______________________ _________________ ____________________
6. _______________________ _________________ ____________________
7. _______________________ _________________ ____________________
Page 5
7. List all owned, leased, or rented residential premises and any owned, leased, or rented farm, timber or
undeveloped land.
Address No of Farming? No. of Pool? Fenced?
Families Acres
1. _______________________ _________ Yes No _____ Yes No Yes No
2. _______________________ _________ Yes No _____ Yes No Yes No
3. _______________________ _________ Yes No _____ Yes No Yes No
4. _______________________ _________ Yes No _____ Yes No Yes No
5. _______________________ _________ Yes No _____ Yes No Yes No
6. _______________________ _________ Yes No _____ Yes No Yes No
7. _______________________ _________ Yes No _____ Yes No Yes No
8. _______________________ _________ Yes No _____ Yes No Yes No
b. If Yes to Farming, type of Farming:_________________________________________________
c. If Yes to Farming, number of farm employees:___________
Underlying Rental and/or Farm, etc. Carrier, Policy # and Limits:
Insuring Company Policy Number Limits of Liability
1. _______________________ _________________ ____________________
2. _______________________ _________________ ____________________
3. _______________________ _________________ ____________________
4. _______________________ _________________ ____________________
5. _______________________ _________________ ____________________
6. _______________________ _________________ ____________________
7. _______________________ _________________ ____________________
Underlying Information:
8. Do you hold any position with non-profit organizations?……………………………………. Yes No
Homeowners’, condominium owners’, or tenant’s insurance:
Does underlying Personal Liability policy have limits of at least $300,000 and Personal Injury Liability of
$300,000?…………………………………………………………………………………….. Yes No
Page 6
Does your farm owners’ and ranch owners’ policy have limits of $500,000?………………. Yes No
9. Personal Umbrella Policy:
Are we excess over this policy?……………………………………………………………… Yes No
Limits Of Liability
As Shown on Your
Insuring company Policy Number Policy
____________________________ _______________________ __________________________
General Information:
Do you or any member of your household participate in organized racing of any motorized vehicle or
watercraft?……………………………………………………………………………………….. Yes No
Do you or any member of your household have a Personal Umbrella policy with Scottsdale Indemnity
Company?……………………………………………………………………………………….. Yes No
Have you or any member of your household had any Liability claims which exceed $5,000 in the last 5
years?……………………………………………………………………………………………. Yes No
Applicant Statement
The information given in this application is true and complete to the best of my knowledge. I understand that omission or
misstatement of fact in the information given, which if known by Scottsdale Insurance Company or Scottsdale Indemnity Company
would have caused Scottsdale Insurance Company or Scottsdale Indemnity Company to decline this application, is grounds for
voiding this policy. I further understand that minimum coverage limits on basic policies are necessary for full protection under the
Personal Umbrella Policy for which I am applying, and that no insurance will be in effect until the policy is issued.
PRIVACY POLICY:
I have received and read a copy of the “Scottsdale Indemnity Company Privacy Statement and Procedures.” By submitting this
application, I am applying for issuance of a policy of insurance and, at its expiration, for appropriate renewal policies issued by
Scottsdale Indemnity Company and/or other members of the Scottsdale group of insurance companies, I understand and agree that any
information about me that is contained in, or that is obtained in connection with, this application or any policy issued to me may be
used by any company within the Scottsdale group to issue, review, and renew the insurance for which I am applying.
FRAUD WARNING:
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,
APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT’S AND PRODUCER’S SIGNATURES.
This application shall be the basis of the policy of insurance and deemed incorporated therein, should the Company evidence
acceptance of this application by issuance of a policy.
APPLICANT’S SIGNATURE ____________________________________________ DATE_____________
PRODUCER’S SIGNATURE ____________________________________________ DATE_____________
IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: As part of the underwriting procedure, a routine
inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and
mode of living. Upon request, additional information as to the nature and scope of the report, if one is made, will be provided.
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Completed 22 August 2020

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