Insurance Umbrella Proposal

INSURANCE UMBRELLA PROPOSAL

Proposal Date:   Proposal Reference No.:

Applicant / Insured Information

Individual   Partnership   Corporation   LLC   Trust   Other

Phone:   Email:

Date of Birth (individual insureds only):   Federal Tax ID / SSN:

Proposed Policy Details

Proposed Effective Date:   Proposed Expiration Date:

Personal Umbrella   Commercial Umbrella / Excess   Public Entity Umbrella

Underlying Limits Required (state minimum limits for each underlying policy):

Deductible / Self-Insured Retention:   Proposed Annual Premium:

Defense costs included within limit (inside limits)   Defense costs outside the limit (outside limits)

Coverage Summary (select applicable exposures)

Automobile Liability (owned, hired and non-owned)
Commercial General Liability (bodily injury & property damage)
Personal Injury & Advertising Injury
Employer's Liability (excess of Workers' Compensation)
Liquor Liability (if applicable)
Non-owned Watercraft Liability
Excess Only (no additional insuring agreements)

Exclusions and Endorsements

The following standard exclusions ordinarily apply to umbrella policies. Applicant may request consideration for endorsements or limited waivers; any deviation is subject to underwriting approval and may alter premium or terms.

Intentional acts or criminal conduct (exclusion applies)    Request exception/endorsement

Professional / Errors & Omissions liability (typically excluded)    Request exception/endorsement

Pollution liability (unless specifically endorsed)    Request exception/endorsement

War, nuclear reaction, or radiation (exclusion applies)

Beneficiaries / Additional Insureds

Relationship to Applicant:   Percentage of Interest:

Claims & Loss History

Documentation Checklist

Indicate documents submitted with this proposal:

Declarations page(s) of underlying policies
Auto Liability policy forms
General Liability policy forms
Workers' Compensation evidence
Loss runs / claims history (last 5 years)
Prior umbrella policy (if any)
Other supporting documents

Conditions, Representations and Declarations

The Applicant represents and warrants that the statements and particulars contained in this proposal and any attachments are true, complete and accurate to the best of Applicant's knowledge. Applicant acknowledges that the Insurer will rely upon such information in underwriting and issuing any policy. Misrepresentation or omission of material facts may result in voidance of coverage, rescission of any policy, or denial of claims.

It is a condition precedent to coverage that Applicant maintain the required underlying policies with limits and terms acceptable to the Insurer for the duration of the umbrella policy. Failure to maintain such underlying insurance, or any cancellation thereof, shall relieve the Insurer of liability to the extent provided by the policy language.

Applicant agrees to provide prompt written notice of any occurrence or claim which may give rise to a loss under a policy that may be issued. Applicant shall cooperate fully with the Insurer in investigation, settlement, and defense of claims, and shall not admit liability or settle any claim without the Insurer's prior written consent where such consent is required by policy terms.

Defense and settlement provisions: unless otherwise agreed in writing, the Insurer's duty to defend and the allocation of defense costs will follow the terms of the issued policy. Applicant understands that endorsement language may specify whether defense costs are inside or outside the limits of liability.

Subrogation: the Insurer will be subrogated to any rights of recovery the Applicant may have against third parties to the extent of payments made under the policy, except where waiver of subrogation has been expressly agreed by endorsement.

This Proposal is an offer to provide terms and does not constitute a binder of coverage, a policy, or an acceptance by the Insurer. Coverage, limits and terms are subject to underwriting review, acceptance and issuance of a policy form and payment of the required premium.

By signing below, Applicant certifies that all information provided in this Proposal and in any attachments is true and complete. Applicant acknowledges that knowingly providing false information may constitute fraud and may result in denial of coverage or cancellation of any policy issued.

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