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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The Personal Umbrella / Excess Personal Umbrella Application (Risk Placement Services, Inc.) form is 3 pages long and contains:

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  • 15 check-boxes
  • 85 other fields

Country of origin: US
File type: PDF

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I. INSTANT QUOTE INFORMATION
Applicant’s name: ________________________________________________________________________ Occupation: __________________________
Applicant type: Individual(s) Trust Limited liability company Limited liability partnership Limited partnership Estate
NOTE: Any applicant type other than individual(s) requires a completed Supplemental Questionnaire to be submitted.
Applicant’s email address or primary contact: ______________________________________________________________________________________
Address of primary residence:____________________________________________________________________________ Same as mailing address
City:_________________________________________________________________ State:_______________________ Zip: _______________________
Primary Personal Umbrella
Underlying personal liability limit: ___________________________ Personal form Commercial form
Underlying auto bodily injury liability limit: ____________________ Personal form Commercial form
Excess Personal Umbrella. If so, please provide the underlying primary umbrella limit: ________________________________________________
1. Does the applicant or any resident of the applicant’s household currently or have they at any time had
Yes No
an occupation as an elected or appointed federal or state political gure, professional athlete or coach,
entertainer, media personality or a senior executive or ofcer of a publicly traded company?
2. Has the applicant or any resident of the applicant’s household had a liability loss greater than $50,000 in the past
Yes No
ve years or is there an open liability claim or lawsuit pending against them?
3. Does the applicant or any resident of the applicant’s household operate any business at any owner-occupied residence?
Yes No
4. Does the applicant or any resident of the applicant’s household own any exotic pets?
5. Is there an animal exclusion on any primary homeowners or comprehensive personal liability policy?
6. Is there a dog exclusion on any primary homeowners or comprehensive personal liability policy?
Yes No
7. Does the applicant own or lease any location used for farm or ranch operations?
NOTE: If “yes,” please submit a completed Supplemental Farm Application.
8. In addition to the primary residence:
a. How many owner occupied secondary residences? _____________________________________________________________________________
b. How many 1-4 family residential units rented to others (Duplex = 2 units)? ____________________________ Personal form Commercial form
I. Are any owned or leased locations used as rooming houses, student housing other than a college dormitory room,
Yes No
assisted living facilities or group home facilities?
9. Are any locations leased to others for hunting? Yes No
10. How many automobiles or motor homes are owned or furnished for the regular use of any operator in the household?:
11. How many motorcycles or scooters are owned or furnished for the regular use of any operator in the household? ______________________________
12. How many recreational vehicles (vehicles not licensed for road use) are owned or furnished for the regular use of
any operator in the household? _______________________________________________________________________________________________
13. Any watercraft? (If "Yes", please complete watercraft information section below) Yes No
Operator Information for automobiles, watercrafts and recreational vehicles: NOTE: Please list all household members or regular operators,
age 14 or older, regardless of whether or not they have a license.
Personal Umbrella / Excess Personal Umbrella Application
Year (Make and Model) Length Type: Sailboat, Powerboat,
or Jet Ski
Max
Speed
Total
HP
Waters Navigated:
U.S. Coastal/Inland or
International
Underlying
Liability Limit
Household
Member
Or Regular
Operator
Date of
Birth
License Number
(N/A if not licensed)
License
State
Moving Violation
Convictions
(Last 3 Years)
Major Moving
Violation
Convictions
(Last 3 years)
At Fault
Accidents
(Last 3 years)
Drug Alcohol
Related
Offenses
(Last 5 Years)
Yes No
Yes No
Yes No
page 1 of 3
PU / EPU 9/15 – USLI
CARRIER:
Remarks
*Majormovingviolationconvictionsinclude,butarenotlimitedto,speedingtwenty-veormoreoverthepostedspeedlimit,
evading the police, leaving the scene of an accident, vehicular homicide, driving under a suspended license and reckless driving.
II. APPLICANT INFORMATION
page 2 of 3
PU / EPU 9/15 – USLI
FRAUD STATEMENTS
Alabama, Arkansas, District of Columbia, New Mexico, Rhode Island and West Virginia: 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.
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.
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.
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 commits a fraudulent insurance act.
Maine 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 Fraud Statement: 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.
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 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.
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.
Kentucky, Pennsylvania AND Ohio 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, Virginia 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 include imprisonment, fines and denial of insurance benefits.
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.
STATE NOTICES
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.
Florida Surplus Lines 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 and Illinois Punitive Damage 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.
Maine Notice: The insurer is not permitted to withdraw any binder once issued, but a prospective notice of cancellation may be sent and coverage denied for
fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.
page 3 of 3
PU / EPU 9/15 – USLI
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.
Ohio Representation Statement: 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. THE INSURED UNDERSTANDS AND AGREES THAT ANY MATERIAL MISREPRESENTATION
OR OMISSION ON THIS APPLICATION WILL ACT TO RENDER ANY CONTRACT OF INSURANCE NULL AND WITHOUT EFFECT OR PROVIDE THE
COMPANY THE RIGHT TO RESCIND IT.
Utah Punitive Damages 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.
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: ______________________
The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s decision to provide the
requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this
Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring
prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer
immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium
charged, based on the Insurer’s underwriting guides. 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.
Applicant’s signature: ______________________________________________________________________ Title: ___________________________________
President, Chairperson of the Board, Managing Member, or Executive Director
Date:_____________________________________________________
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Personal Umbrella Excess Personal Umbrella Application (Risk Placement Services, Inc.)

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Completed 23 November 2020

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