Insurance Umbrella Document

INSURANCE UMBRELLA DOCUMENT

1. Insured Information

Insured Name:

Date of Birth (if individual insured):     Tax ID / SSN (or Business EIN):

2. Policy & Coverage Details

Policy Type: Personal Umbrella Commercial Umbrella Excess Liability

Self-Insured Retention / Deductible:     Annual Premium:

Policy Period From:     To:

3. Underlying Insurance (Provide current underlying policy declarations)

Underlying Policy 1

Underlying Policy 2

4. Coverage Selection & Limits

Select Covered Exposures (check all that apply):

Bodily Injury & Property Damage Liability Personal Injury / Advertising Injury Defense Costs in addition to Limit

Automobile Liability Excess Coverage Employers Liability Excess Contractual Liability Excess

5. Exclusions & Limitations

The following exclusions commonly apply to umbrella/excess policies. By signing this document the insured acknowledges that the policy will include exclusions for: intentional acts, expected or foreseeable injury, professional errors and omissions (unless specifically endorsed), pollution and environmental hazards (unless specifically endorsed), war and nuclear hazard, and any coverage excluded by the underlying policy. Such exclusions may be amended by endorsement and will be set forth in the policy declarations and endorsements.

Acknowledgement of standard exclusions: I acknowledge that the standard exclusions will apply unless amended by endorsement.

6. Claims History

Any claims, suits or incidents in the past five (5) years that could give rise to a claim under the proposed policy? Yes No

7. Additional Insureds / Beneficiaries

List any Additional Insureds, Loss Payees, or Parties to be Named on the Policy. Include relationship and percentage of interest if applicable.

8. Attachments Checklist

Include the following with this application (check all attached):

Underlying policy declarations pages Loss runs for last 5 years Auto schedule (if applicable)

9. Declarations, Authorizations and Certification

Insuring Agreement Summary: Subject to the terms, conditions, exclusions and endorsements of the policy, the insurer will provide liability coverage in excess of the underlying insurance identified herein up to the Limit of Liability specified. Coverage is subject to the applicable Self-Insured Retention, the terms of the underlying policies and any endorsements executed as part of the policy.

Conditions: The insured must give prompt notice of any loss or claim, cooperate with the insurer in defense and investigation, preserve rights of recovery for subrogation, and provide requested documents and access for audit. The insurer may cancel or nonrenew in accordance with policy terms; premium adjustments may apply for misrepresentation, understatement of exposure or increase in hazard.

Fraud and Misrepresentation: It is a material breach of this application and any resulting policy for any insured to knowingly provide false, incomplete or misleading statements or representations. Such conduct may result in cancellation, rescission of coverage, or denial of claims to the extent permitted by applicable law.

Authorization: The insured authorizes the insurer to obtain underwriting, claim and loss history, and other information necessary to evaluate and service this policy from prior insurers, third-party administrators, and other legitimate sources. The insured also authorizes release of information to those parties for legitimate underwriting, audit or claim purposes.

Choice of Law and Dispute Resolution: Any dispute arising under the policy shall be governed by the law specified in the policy and may be subject to arbitration or alternative dispute resolution if provided by endorsement or policy provision.

Certification: By signing below, the undersigned certifies that to the best of their knowledge and belief the statements contained in this document and any attachments are true, complete and correct, and that no material fact has been omitted. The undersigned further acknowledges that coverage, limits, exclusions and conditions will be set forth in the issued policy and that this document does not bind coverage until accepted and countersigned by the insurer.

I certify that the information provided is accurate and may be relied upon for underwriting: I certify

10. Entity Type

Indicate the legal form of the insured (check one or more as applicable):

Individual Corporation Limited Liability Company (LLC) Trust Partnership

11. Signature and Certification

The undersigned represents that they are authorized to complete this application on behalf of the named insured and acknowledges that signing this document constitutes a certification under penalty of law as to the veracity of the statements herein.

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