Request a Quote for Umbrella Insurance

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Welcome to our Umbrella Insurance Quote Request form. This simple process takes just 5-15 minutes.

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Business Information

Company Name:
Email:
Business License:
Business Phone:
Company Address:
City:
State:
Zip:
Nature of Business:
Business Type: Proprietorship Corporation Partnership LLC

Date Formed (Corp or LLC): / /
Number of Owners/Partners/Members:
How long in business?
Bank (Business Account):
Phone #:
Account #:
Balance:
Previous Bonding Company:
Reason for Changing Bonding Co.:

Please answer any that apply:

Advertisers Liability

Media Used:
Annual Cost:
Any Smokers In House? Yes No
Any Coverage Provided Under Agency's Policy? Yes No

Aircraft Liability

Does applicant own/lease/operate aircraft? Yes No

Auto Liability

Are explosives, caustics, flammables or other dangerous cargo hauled? Yes   No
Are passengers carried for a fee? Yes   No
Any units not insured by underlying policies? Yes   No
Are any vehicles leased or rented to others? Yes   No
Are hired and non-owned coverages provided? Yes   No

Contractors Liability

Is bridge, dam, or marine work performed? Yes   No
Describe typical jobs performed:
Annual Cost:
Are any vehicles leased or rented to others? Yes   No
Are hired and non-owned coverages provided? Yes   No

Employers Liability

Is applicant self-insured in any state? Yes No

Subject to:

Jones Act
FELA
Stop Gap
Other
Please describe:

Incidental Malpractice Liability

Is bridge, dam, or marine work performed? Yes No
Is bridge, dam, or marine work performed? Yes No
No. of doctors:
No. of nurses:
No. of beds:

Pollution Liability

Do current or past products, or their components, contain hazardous materials that may require special disposal methods?

Indicate the coverages carried:

GL with standard ISO pollution exclusion
GL with standard sudden & accidental only
GL with pollution coverage endorsement
Separate pollution coverage

Product Liability

Are missiles, engines, guidance systems, frames or any other product used/installed in aircraft? Yes   No
Any foreign operations, foreign products distributed in the USA or US products sold/distributed in foreign countries? Yes   No
Product liability loss in past three (3) years? Yes   No

Gross sales from each of past three (3) years:

Protective Liability

Describe independent contractors:

Watercraft Liability

Does applicant own or lease watercraft?? Yes No
# Owned
Length
Horsepower

Apartments, Condominiums, Hotels, Motels # Stories
# Units
# Swimming Pools
# Diving Boards

Disclaimer

Your rate quote depends on the accuracy of the details you provide on our form. Please be aware that not all limits and coverage selections are appropriate for everyone.

Not all situations and needs can be addressed by our form. If you require personal assistance, please contact us.