Insurance Umbrella Coverage Form

INSURANCE UMBRELLA COVERAGE FORM

Insured / Applicant Information

Insured Name:

Individual Corporation LLC Partnership Other

Policy & Underlying Insurance

Premium Payment Frequency: Annual Semi-Annual Quarterly Monthly

Coverage Selections

Select the umbrella coverages to be afforded under this policy (select all that apply):

Personal Liability Excess Automobile Liability Excess Commercial General Liability Excess Employers Liability Excess Professional Liability Excess (specify underlying limits)

Claims & Loss History

Has the insured sustained any claims, losses, or incidents in the past five (5) years that would fall within the proposed umbrella coverage? Yes No

Has any umbrella or underlying liability policy been cancelled or non‑renewed in the past five (5) years? Yes No

Exclusions (Representative)

The following are standard exclusions under this umbrella coverage unless otherwise specifically endorsed: (a) intentional acts or criminal conduct; (b) professional services or advice rendered for a fee unless scheduled; (c) aircraft, watercraft and autos not declared or not covered by required underlying policies; (d) pollution and environmental liability except as specifically endorsed; (e) employer’s workers’ compensation and employers’ liability where statutorily excluded; (f) war, nuclear hazard, and governmental seizure. This list is illustrative and not exhaustive; final exclusions will be set forth in the policy.

By initialing, the applicant acknowledges receipt and review of the representative exclusion summary above and understands additional exclusions may apply in the issued policy. Initials:

Beneficiary / Additional Payee Information

Name of Beneficiary / Additional Payee:

Underwriting Declarations & Applicant Certification

The undersigned certifies that the statements and answers contained in this application are true and complete to the best of the undersigned's knowledge and that no material facts have been omitted. The undersigned understands that any material misrepresentation or omission may void coverage and authorize the insurer to rescind or deny coverage as permitted by law. The insurer is authorized to obtain loss runs, claim information and other underwriting information from prior carriers and claim administrators.

The applicant agrees to cooperate with the insurer in the defense and investigation of any claim and to assign to the insurer any rights of recovery against responsible third parties to the extent of indemnity paid. The applicant acknowledges that issuance of the umbrella policy is subject to review of underlying policies and applicable endorsements and that the final policy may include additional terms, conditions and exclusions.

I hereby authorize the release of information necessary for underwriting and claims handling, including but not limited to employment records, driving records, loss history, and prior policy information. I further acknowledge that premium quotes are subject to change pending verification of the information provided herein.

Applicant agrees to notify the insurer promptly of any material change in exposure or underlying coverage. Coverage will become effective only upon issuance of an umbrella policy and payment of any required premium unless otherwise agreed in writing by the insurer.

Applicant certification: I certify that the information provided on this form is true, accurate, and complete and that I have read and understand the declarations above.

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