Insurance Umbrella RCC

INSURANCE UMBRELLA RCC

Applicant / Insured Information

Individual    Corporation    LLC    Partnership    Trust    Other

Date of birth (if individual):

Policy Details

Underlying Insurance Schedule

List primary underlying policies that this umbrella excesses. Attach certified copies of underlying policies and endorsements where required.

Coverage Options (select all that apply)

Bodily injury liability    Property damage liability    Personal/Advertising injury    Auto liability
Employers' liability    Liquor liability    Worldwide coverage extension    Defense outside limits

Exclusions

The following standard exclusions apply unless an endorsement provides otherwise: claims arising out of pollution, professional errors and omissions, punitive or exemplary damages where unenforceable under law, intentional acts or expected injury, nuclear hazard, asbestos, and war or terrorism. Any additional insurer-imposed exclusions are to be listed below.

Conditions, Duties and Claims Reporting

It is a condition precedent to coverage that the insured shall: (a) give prompt written notice of any occurrence reasonably likely to give rise to a claim under this policy; (b) cooperate fully with the insurer in investigation and defense; and (c) forward any claim, suit, demand or notice received to the insurer immediately. Failure to provide timely notice or to cooperate may void coverage to the extent prejudice results.

Required notice period:

Subrogation and recovery: The insurer shall be subrogated to all rights of recovery the insured may have against any third party for loss paid under this policy. The insured shall cooperate in preserving such rights and shall execute instruments required to secure the insurer's subrogation rights.

Beneficiary / Additional Insured Designation

Additional insureds or beneficiary designations, if applicable, are subject to the terms and limitations of this umbrella policy and underlying policies. List all parties to be designated as additional insureds or beneficiaries below and indicate the nature of their interest.

Claim / Loss Information (if reporting)

Photographs    Repair estimates    Police report    Medical records    Other

Declarations and Certification

The undersigned certifies that the information contained herein is true and complete to the best of the undersigned's knowledge and belief. The undersigned understands that misrepresentation, omission or concealment of material facts may result in denial of coverage, rescission of the policy, or other remedies available to the insurer at law or in equity. Coverage provided by this umbrella policy is subject to all terms, conditions, endorsements and exclusions of the policy and the underlying primary policies.

The insured authorizes the insurer to obtain and exchange information with other insurers, claims administrators, and relevant third parties for underwriting and claims handling purposes. The insured agrees to cooperate with the insurer in the defense and settlement of claims and to provide all documentation reasonably requested.

Fraud Warning:

Any person who knowingly presents false information in an application for insurance may be subject to civil or criminal penalties under applicable law. All claims will be investigated and false claims may be prosecuted.

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