Insurance Umbrella Paperwork

INSURANCE UMBRELLA APPLICATION AND DECLARATIONS

Applicant / Insured Information

Policy Details

Policy type: Personal Umbrella Commercial Umbrella Excess Liability

Policy period: From to

Underlying Insurance Information

Applicant must maintain underlying policies specified below at minimum limits. Provide carrier and limits for each underlying coverage.

Coverage Options & Endorsements

Select optional coverages to be considered for quotation. Coverage provided only if specifically endorsed to the policy.

Excess / Umbrella over auto liability

Excess / Umbrella over homeowners liability

Watercraft liability endorsement

Employment practices liability (if available)

Other (specify below)

Exclusions & Important Conditions

The policy will not cover loss arising from: intentional acts by insured, professional services unless specifically endorsed, punitive or exemplary damages where prohibited by law, nuclear hazard, war, willful fraudulent acts, and any other exclusions shown in the final policy form. These exclusions are illustrative and are subject to the final policy language.

Applicant acknowledges obligation to maintain the underlying policies at the limits required by the insurer and to notify the insurer promptly of material changes in exposure. Failure to maintain required underlying coverage or material misrepresentation may result in rescission or denial of coverage.

I acknowledge that I have read and understand the exclusions and conditions described above. Initials:

Loss History / Claims

Yes No

Documentation Checklist

The following documents are required for a complete quotation. Check those included with this submission.

Underlying policy declarations pages

Loss runs (last 5 years)

Auto schedule (if auto coverage requested)

Homeowners / Dwelling policy declarations

Business liability policy declarations

Beneficiary / Payee for Policy Proceeds

Note: Umbrella liability proceeds are normally payable to claimants; the following designation applies only to any return premium or any residual payment due to the named insured at policy termination.

Declarations, Authorizations, and Signature

I declare that, to the best of my knowledge and belief, the statements and answers given in this application are true, complete and correctly recorded. I understand that this information will be relied upon by the insurer in determining eligibility and underwriting terms. I acknowledge that any material misrepresentation, omission or concealment of fact may result in denial of coverage, rescission of the policy, or adjustment of coverage terms.

I authorize the insurer and its representatives to obtain and verify underwriting information, including but not limited to loss history from prior insurers, inspection reports, and any other information pertinent to the underwriting of this risk. I further authorize the release of information to reinsurance or regulatory entities where required.

I agree to notify the insurer promptly of any material change in operations, exposures, or underlying coverages. I understand that the final coverage, terms, limits, and exclusions will be set forth in the policy and endorsements issued by the insurer; this application does not bind coverage unless and until a policy is issued.

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