Fillable Personal Umbrella/Excess Personal Umbrella Application (Risk Placement Services, Inc.)

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Personal Umbrella/Excess Personal Umbrella Application (Risk Placement Services, Inc.)

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YOU CAN OBTAIN A QUOTE BY PROVIDING THE INFORMATION IN THE INSTANT QUOTE SECTION, SUBJECT TO THE REMAINDER PROVIDED PRIOR TO BINDING.
PCL 10/08
page 1 of 3
Personal Umbrella/Excess Personal Umbrella Application
I. INSTANT QUOTE INFORMATION
Instant Quote is only available for accounts with no losses in the past 3 years. If there is loss h
i
istory, please complete the entire application.
Applicant’s Name:__________________________________________________________________________________________________________
Email Address of primary contact: ___________________________________________________________________________________________
Location Address: _________________________________________________________________ Same as mailing address
City ______________________________________________________ State _______________________ Zip: ________________________
Primary Personal Umbrella
Underlying CPL Limit: ____________________________________________________
Underlying Auto Liability Limit: ______________________________________________
Excess Personal Umbrella
Underlying Umbrella Limit: ________________________________________________
Does the applicant, or any resident of the applicant's household, currently have or ever had an occupation
as a professional athlete or coach, entertainer, media personality, officer of a publicly traded company,
or an elected or appointed federal or state political figure? Yes No
Is there a Farm or Ranch type risk with farm animals, farming revenues $5,000 or more or owning more than
100 acres at any location to be covered under this policy? Yes No
NOTE: All "Yes" responses require the submission of the Farm Supplemental Application (FPCESA)
Other than primary residence, enter the number of secondary homes and /or the number of 1-4 family
residential units rented to others. (2 family duplex = 2 units) ________
How many automobiles, motorcycles, motor homes and other vehicles licensed for road use are owned or
furnished for the regular use of all drivers in the household? ________
How many recreational vehicles (vehicles not licensed for road use) are there in the household? ________
Any Watercraft? If Yes, Please complete watercraft information section Yes No
Watercraft Information
Please list all watercraft owned, leased, chartered, or furnished f
o
or regular use.
*Powerboats (other than Jet-Skis) with speed capabilities exceeding 50 MPH are ineli
g
gible.
Driver Information - Please enter the Number of Drivers: Driving Record Information - Please e
n
nter the Number of:
Under the age of 19 ______________ Moving Violations (over the past three years) ______________
Between the ages of 20 and 22 ______________ Major Moving Violations (over the past three years) ______________
Between the ages of 23 and 75 ______________ At-Fault Accidents (over the past three years) ______________
Over the age of 75 ______________ Drug/Alcohol Offenses (over the past ten years) ______________
COMMITTED
MAKING
TO
A
D
IFFERENCE
*Major moving violation convictions include, but are not limited to, speeding 25 or more over the p
o
osted limit, evading the Police, leaving the
scene, vehicular homicide, driving under a suspended l
i
icense, and reckless driving.
Important Notice Regarding the Fair Credit Reporting Act:
I understand that as part of the underwriting procedure, a consumer report may be obtained in connection with the application for insurance
and subsequent amendments and renewals. Such reports may include information regarding my driving record. Information collected by the
Company or its authorized representatives may, in certain circumstances, be disclosed to third parties without my authorization. I have the right
to review my personal information in the Company files and can request correction of any inaccuracies.
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.
Applicant’s Signature: ____________________________________________________________________________ Date: ________________________
CRAFT
NUMBER
YEAR DESCRIPTION
(MAKE AND MODEL)
LENGTH TYPE
1. SAILBOAT 2. OUTBOARD
3. JET SKI / WAVE RUNNER
4. INBOARD/OUT DRIVE
5. INBOARD
MAX
SPEED
TOTAL
HP
WATERS NAVIGATED
1. INLAND U.S.
2. COASTAL U.S.
3. INTERNATIONAL
WATERS
Policy # /
Liability Limit
1
2
click to sign
signature
click to edit
II. ELIGIBILITY QUESTIONS
(NOTE: Attach a statement of details for all “yes” answers to the following questions)
1. Does the applicant or any member of the applicant’s household currently have any active policies
with United States Liability Insurance Company, Mount Vernon Fire Insurance Company,
or U.S. Underwriters Insurance Company? Yes No
2. Has the applicant or any resident of the applicant's household been convicted of a felony in the past 10 years? Yes No
3. Has the applicant or any resident of the applicant's household had a liability loss greater than $50,000
in the past 5 years or is there an open liability claim or lawsuit pending against them? Yes No
4. Are any locations considered rooming or boarding houses? Yes No
5. Are any locations considered student housing, subsidized housing, or assisted living/group home facilities? Yes No
6. Is there a pool at any location that is either unfenced or has a diving board or waterslide? Yes No
7. Is there any Business exposure or operation covered by the Primary Homeowners or CPL policy? Yes No
8. Are any locations leased to others for hunting, fishing, or other sporting or recreational purposes? Yes No
9. Does the applicant or any resident of the applicant's household own any dogs or exotic pets? Yes No
10. Is there a Dog or Animal Exclusion on any primary Homeowners or Comprehensive Personal Liability policy? Yes No
11. Is any underlying coverage, other than Automobile, written on a Commercial Policy Form? Yes No
12. Is the underlying Auto Coverage being provided entirely by a Business Auto or Garage Policy? Yes No
13. Does any household operator have any restriction on his/her driver's license other than glasses or
corrective lenses? Yes No
14. Do any primary policies contain any sub-limits, have reduced limits of liability, or exclude coverage for
specific individuals or exposures? Yes No
15. Is there currently, or during the next 12 months will there be, any construction or renovation at any
residential 1-4 family residence or condominium owned by or rented to the applicant? Yes No
16. I Is the underlying liability for all locations provided on Personal Lines forms? Yes No
Residential Properties/Rental units and Apartments/Farms/Vacant Land
*Dwellings with five
or more units are ineligible
Operator Information (Automobiles, Watercraft, Recreational Vehicles)
*Major moving violation convictions include, but are not limited to, speeding 25 or more over the pos
t
ted limit, evading the Police, leaving the
scene, vehicular homicide, driving under a suspended lic
e
ense, and reckless driving.
PCL 10/08- United States Liability Insurance Group
page 2 of 3
LOCATION OCCUPANCY LIABILITY LIMIT
Primary residence address
# Units ____________________
Owner occupied
Tenant Occupied # Units ____
Farm # Acres______________
Vacant Land # Acres _______
Owner occupied
Tenant Occupied # Units ____
Farm # Acres______________
Vacant Land # Acres _______
DRIVER NAME DATE
OF
BIRTH
LICENSE
NUMBER
LICENSE
STATE
MOVING
VIOLATION
CONVICTIONS
(LAST 3 YEARS)
*MAJOR MOVING
VIOLATION
CONVICTIONS
(LAST 3 YEARS)
AT FAULT
ACCIDENTS
(LAST 3 YEARS)
DRUG OR
ALCOHOL
RELATED
OFFENSES
(LAST 10 YEARS)
III. ADDITIONAL APPLICANT INFORMATION
Applicant’s Mailing Address:____________________________________________________ (if different than Primary Residence address)
City:______________________________________________________ State: ______________________ Zip: ________________________
Phone: _______________________________________________________________________________________
Virginia Notice:
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.
Minnesota Notice:
The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified 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.”
Colorado
F
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 Statem
e
ent:
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.
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.
New Jersey Fraud Stat
e
ement:
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 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.
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.
Oklahoma Fraud Statement: WARNIN
G
G:
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.
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.
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail Agency Name: ____________________________________ License #: ____________________________________________________________
Main Agency Phone Number: ____________________________________________________________________________________________________
Agency Mailing Address: _________________________________________________________________________________________________________
City: ________________________________________ State: __________________ Zip: ________________________________
PCL 10/08- United States Liability Insurance Group
page 3 of 3
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Personal UmbrellaExcess Personal Umbrella Application (Risk Placement Services, Inc.)

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Completed 23 November 2020

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