Personal Umbrella or Excess Liability Policy Application

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Producing Office: Producer Name: E-mail: Address: Phone #: Fax #:

Applicant's Name Effective Date    Mailing Address Desired Limit (in millions) $ Residence Address Type: Personal Umbrella Personal Excess Liability (Excess over other umbrella*) Employment Applicant's Occupation: Applicant's Employer Name and Address: Years Employed: Co-Applicant's Occupation: Co-Applicant's Employer Name and Address: Years Employed: Underlying Insurance: Type of Coverage Carrier Policy # Policy Period Minimum Underlying Limits Your Underlying Limit Automobile $250/$500/$100 or $500 CSL $ Uninsured/Underinsured $250/$500/$100 or $500 CSL $ Homeowner or CPL $300,000 $ Rental Dwellings $300,000 $ Farms, Vacant Land $300,000 $ Watercraft $300,000 $ Jet Ski, Wet Bike $500,000 $ Recreational Vehicle $300,000 $ Underlying Umbrella* $1,000,000 $ Incidental Business $1,000,000 $ Other $1,000,000 $ Real Estate: List all owned, leased or occupied Residences, Buildings, Farms, Vacant Land, etc. # Location (street, city, state) #Units Yr Built Occupancy (primary, secondary, rental, vacant, etc.) 1 2 3 4 5 6 Automobiles and Recreational Vehicles: List all autos owned, leased or furnished for regular use (Motorcycles, Snowmobiles, etc.) # Year Co. Car? Make/Model/Type # Year Co. Car? Make/Model/Type 1 Yes 2 Yes 3 Yes 4 Yes 5 Yes 6 Yes 7 Yes 8 Yes 9 Yes 10 Yes 11 Yes 12 Yes Watercraft: List all watercraft (including Jet Skis, Wet Bikes, etc.) owned, leased, chartered or furnished for regular use # Year/Make/Model Length Engine Type / HP Max. Speed # of Paid Crew Waters Navigated (inland, coastal, etc.) 1 2 3 4 5 6 Operator Information: List all Members of Household and all Operators of Vehicles/Watercrafts/RV’s # Name Drivers License # State Date of Birth Vehicle, Craft, % of Use 1 % 2 % 3 % 4 % 5 % 6 % Driving Record Information: List # of traffic violations and/or motor vehicle accidents for all Operators indicated above during past 3 years. # Name # Moving Violations # Major Violations # Minor At-Fault Accidents # Major At-Fault Accidents 1 2 3 4 5 6 General Information - Explain all "Yes" Responses in Remarks (If additional space is needed, please attach a separate sheet) Yes No Yes No 1) Any liability losses (homeowners, etc.) exceeding $5,000 or more in the past 5 years? 2) Do you employ any residence employees? Full-time or part-time? Full-time  Part-time # of employees 2) Does any underlying policy have reduced limits of liability or eliminate coverage for specific exposures, drivers, animals, watercraft, locations, etc.? 8) Do you or any household member have mental/physical impairments that affect driving ability? 3) Any business/professional activities (including farming or daycare) included in primary policies? Does it cover incidental business activities? 9) Any umbrella coverage declined, cancelled, or non-renewed in last 5 years? 4) Do you or any household member hold any non remunerative positions? Details? 10) Do your underlying insurance policies include Personal Injury (libel/slander) coverage? 5) Any real estate, vehicles, watercraft, aircraft owned, hired, leased or regularly used, not covered by underlying insurance? 11) Does any household members have an occupation of a professional entertainer, athlete, media personality or local, state or federal political past or present? 6) Do any of the properties you own or rent have a swimming pool on premises that have a diving board and/or are not fenced? Any coverage limitations? 12) Any pets (wild or domestic) on the premises? Type(s)? Any coverage restrictions or exclusions? Yes No Remarks (Please indicate question# next to explanation): Optional Uninsured/Underinsured (UM/UIM) Motorist Coverage: (EXTRA CHARGE) I would like to purchase, at additional charge, uninsured/underinsured motorist coverage as part of my Umbrella/Excess Liability policy: Accept Reject If you ‘ accept,’ then you agree both that you have purchased underlying uninsured/underinsured motorist limits on all other motor vehicles that you own equal or greater than the Minimum Underlying Limits Automobile Liability limits of this policy, and you are electing to purchase certain valuable coverages which protect you and your family, then check this box: If you ‘reject’ the uninsured/underinsured motorist coverage, then you agree you have not purchased underlying uninsured/underinsured motorist limits on all other motor vehicles that you own equal or greater than the Minimum Underlying Limits Automobile Liability limits of this policy, or you are electing not to purchase certain valuable coverages which protect you and your family, then check this box: 2. Optional Personal Injury Coverage: Yes No (This requires Personal Injury Coverage on your underlying insurance.) 3. Optional Incidental Business Coverage: Yes No (This requires Incidental Business Coverage on your underlying insurance.)

Please submit to my following underwriter Kathy Wilson Robin Schommer Ciara Quinones Brian Botwinick - or- I do not have an assigned underwriter please assign me an underwriter