Insurance Umbrella Policy Application

INSURANCE UMBRELLA POLICY APPLICATION

Applicant / Insured Information

Applicant Name:

Policy Details

Policy Type: Umbrella Liability

Underlying Insurance / Attachments

List principal underlying policies (Carrier / Policy Number / Limits). Attach declarations and loss runs with application.

Declarations pages for underlying policies
Loss runs for the past 5 years
Financial statements (if requested)
Operations description and payroll schedule

Coverage Selection

Select coverages requested under the umbrella policy. Coverage provided is subject to underwriting and applicable policy terms, conditions and exclusions.

Bodily Injury and Property Damage Liability Excess
Personal and Advertising Injury
Automobile Liability Excess (specify underlying auto policy below)
Employer's Liability Excess
Other (describe below)

Exclusions and Acknowledgements

The following are typical exclusions under any issued umbrella policy. Applicant must acknowledge awareness of exclusions below. Coverage will be subject to full policy exclusions, limitations and endorsements.

Exclusion for war, acts of foreign enemies and terrorism as defined in the policy
Exclusion for intentional acts, criminal acts, or fraudulent conduct by insureds
Professional liability / errors & omissions excluded unless specifically endorsed
Pollution and contamination excluded unless specifically endorsed
Asbestos and mold related claims excluded

Beneficiaries / Additional Insureds

List any additional insureds, loss payees or entities to be named on the policy. Provide relationship and allocation of any recoverable proceeds.

Claims / Loss History (Past 5 Years)

Provide details for all claims, suits, incidents or occurrences that may give rise to a claim. Attach complete loss runs where available.

Underwriting Questions

Answer the following questions fully. If yes, provide details in the space provided and attach supporting documentation.

Has the applicant had any policy canceled or non-renewed in the past five years?

Is the applicant involved in any pending litigation or regulatory proceeding?

Declaration and Authorization

I certify that the information contained in this application and any attachments is true, complete and correct to the best of my knowledge. I understand that this application is subject to underwriting review and that coverage cannot be bound or altered except by issuance of a policy document containing the insurer's signatures, terms, conditions and exclusions. I authorize the company and its representatives to obtain information and records relevant to this application, including but not limited to loss runs, credit information, and other underwriting data. I understand that any material misstatement or omission may be grounds for denial of coverage or rescission of the policy.

The applicant agrees to notify the insurer promptly of any material change in the risk or operations described herein. Acceptance of any premium does not constitute acceptance of any risk or bind coverage unless expressly agreed in writing by the insurer.

Producer / Broker Information

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