Insurance Application Safeco Umbrella

INSURANCE APPLICATION SAFECO UMBRELLA

Use this application to request personal umbrella liability insurance through the Safeco Umbrella program. Completion and signature below certify that all statements in this application are true and complete to the best of the applicant's knowledge. False statements or material omissions may result in declination, cancellation, or denial of coverage and may affect coverage for a claim.

Applicant / Insured Information

Underlying Liability Policies

Provide current primary liability policies that sit beneath the requested umbrella. Declarations pages and proof of limits must be submitted with this application.

Automobile Liability

Homeowners / Personal Liability

Other Underlying Policies

Requested Umbrella Policy Details

Coverage Options (select all that apply)

Personal umbrella liability

Non-owned automobile liability (incl. employer's non-owned autos)

Watercraft liability (specify horsepower and use in other information)

Liability excess for rental properties (attach lease and schedule)

Exclusions & Important Notices

The umbrella policy will contain standard exclusions including, but not limited to: intentional acts, bodily injury or property damage arising out of business or professional pursuits not disclosed and accepted in writing, aircraft (unless specifically scheduled), war, nuclear hazards, and pollution except as may be expressly provided by endorsement. Coverage is provided only to the persons and locations listed on the policy declarations and is excess of the underlying primary limits required by the insurer.

I acknowledge receipt of, and understand, the exclusion summary above and certify that no material facts have been omitted. Applicant must notify the insurer promptly of any material change in exposures or underlying policies.

I acknowledge and accept the exclusions and notices described above.

Prior Claims / Loss History (past 5 years)

Any open claims or losses in the prior five (5) years must be disclosed. Failure to disclose may be grounds for denial of coverage or rescission.

Any claims or losses in past 5 years?   Yes   No

Documentation Checklist (submit with application)

Declarations pages for all underlying policies showing limits and premiums

Loss runs for the last five (5) years

Photographs or diagrams (if applicable)

Police reports or incident reports (if applicable)

Beneficiary / Payee Information

Provide beneficiary or payee information for return of unearned premium or any payments payable under policy provisions where a payee designation is permitted.

Declarations and Applicant Certification

The undersigned applicant declares that the information contained in this application is true, complete and correctly recorded. The applicant understands that this application, together with any attachments and required documentation, will form the basis of any policy issued. The applicant authorizes the insurer and its agents to obtain loss history, credit and underwriting information from third parties, and to disclose application and claim information to other insurers and agents for underwriting and claim handling purposes.

The applicant understands and agrees that coverage will not be bound until the insurer issues a policy or binder and the required premium is received. Coverage, if issued, will be subject to the terms, conditions, limitations and exclusions contained in the policy. Misrepresentations or omissions of material fact may void coverage or result in rescission. Fraud or intentional misstatement in the application will be grounds for denial of claims and termination of coverage.

By signing below, the applicant certifies under penalty of perjury that all statements made in this application are true and complete, authorizes the insurer to verify any information provided, and acknowledges receipt of the notice of exclusions and claims reporting requirements.

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