Insurance Umbrella Package

Insurance Umbrella Package

This Insurance Umbrella Package Application and Declaration sets forth the information provided by the Applicant to evaluate eligibility for umbrella/excess liability coverage. Completion of this form does not bind coverage. All statements made herein are material facts to the extent that they influence acceptance or terms of any proposed policy.

Applicant / Insured Information

Date of Birth:

Individual Corporation LLC Trust Other:

Policy Details

Coverage Limit: $    Deductible / Retention: $    Annual Premium: $

Policy Period: From    To

Automobile Liability: $    Commercial General Liability: $

Employers Liability / Workers' Compensation: $

Coverage Options

Personal Umbrella Liability — excess protection over specified underlying personal policies.

Commercial Umbrella Liability — excess for business exposures (subject to underlying requirements).

Defense Costs Inside Limit — defense expense erodes the limit. Defense Costs Outside Limit — defense expenses are paid in addition to the limit.

Aggregate Limit applies Per-occurrence Limit applies

Exclusions and Limitations

The proposed umbrella policy will not provide coverage for losses excluded by the policy form. Typical exclusions include but are not limited to: professional liability (unless expressly endorsed), pollution and contamination exposures, intentional acts and criminal conduct, workers' compensation statutory obligations, liability assumed under contract beyond incidental contractual liability, aircraft and certain watercraft operations, and liability arising from racing or organized competitive events. Punitive or exemplary damages may be excluded or limited by subject-matter or jurisdictional law.

Applicant acknowledges having received and reviewed the policy exclusions and limitations and understands that coverage is subject to the full terms, conditions, exclusions and endorsements of the issued policy.

Applicant acknowledges and understands exclusions and limitations stated above.

Beneficiary / Additional Insureds

Complete one line per named additional insured or beneficiary for payment of covered personal injury proceeds, if any.

Prior Claims and Loss History

Have any claims, suits or incidents been reported to any insurer in the last five (5) years? Yes No

Documentation Checklist

Provide the following with this application (check included):
Signed Declarations and Application Copy of underlying policies and endorsements Loss runs for prior 5 years

Driver list (if coverage includes automobile exposures) Proof of assets or net worth (if requested)

Declarations and Certifications

By signing below, Applicant certifies that the information contained in this application is true, complete and correctly recorded to the best of Applicant's knowledge. Applicant understands that any material misrepresentation, omission or concealment of fact may be grounds for denial of coverage, cancellation or rescission of the policy. Applicant authorizes the insurer and its representatives to obtain pertinent information, including loss history and underwriting data, from third-party sources and prior insurers for the purpose of underwriting and claim handling.

Applicant acknowledges that coverage, if issued, will be subject to policy terms, conditions, limitations, exclusions, endorsements and jurisdictional law. Applicant agrees to provide prompt written notice of any material change in exposure or any occurrence that may give rise to a claim. The insurer reserves all rights of subrogation and recovery as provided in the policy.

Arbitration and governing law: Any dispute arising out of this application or the issuance of a policy may be subject to dispute resolution provisions in the policy. The policy will specify governing law and dispute resolution procedures where applicable.

Applicant certifies and acknowledges all Declarations and Certifications above. Applicant consents to insurer obtaining underwriting and claims information.

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