PERSONAL UMBRELLA APPLICATION

Transcription

1 AGENCY PERSONAL UMBRELLA APPLICATION APPLICANT'S NAME AND MAILING ADDRESS (include county & ZIP+4) DATE (MM/DD/YYYY) CONTACT NAME: PHONE (A/C, No, Ext): FAX (A/C, No): ADDRESS: CODE: SUBCODE: DATE AT RESIDENCE: PRIMARY PHONE # HOME BUS PRIMARY ADDRESS: CELL SECONDARY PHONE # HOME BUS CELL CARRIER NAIC CODE SECONDARY ADDRESS: POLICY NUMBER PLAN FACILITY CODE EFFECTIVE DATE EXPIRATION DATE UMBRELLA INFMATION PRIMARY POLICY INFMATION AUTO PERSONAL LIABILITY TYPE OF POLICY RECREATIONAL VEHICLES EMPLOYERS LIABILITY POLICY AMOUNT OPTIONAL COVERAGES TO APPLY UNINS MOT HOME RENTALS UNINS MOT COVERAGES PREMIUMS CALCULATIONS OTHER RETENTION UNINSURED MOTIST * UNDERINSURED MOTIST * * IF APPLICABLE IN YOUR STATE PAYMENT PLAN ACCOUNT #: BILLING DIRECT BILL AGENCY BILL REMARKS IF DIRECT BILL: BILL APPLICANT BILL MTGAGEE COMPANY NAME/POLICY NUMBER RESIDENCES AUTOMOBILES RECREATIONAL VEHICLES UNINSURED MOTIST UNDERINSURED MOTIST DEPOSIT ESTIMATED TOTAL PREMIUM ACD 610 attached (NOT APPLICABLE IN NC) FULL PAY IF APPLICANT BILL: POLICY PERIOD SINGLE LIMIT MAIL POLICY LIMITS OF LIABILITY BODILY INJURY N / A AGENT APPLICANT PROPERTY DAMAGE N / A Page 1 of ACD CPATION. All rights reserved. The ACD name and logo are registered marks of ACD

2 PROPERTY LIST ALL OWNED, LEASED OCCUPIED PROPERTY, INCLUDING RESIDENCES, BUILDINGS, FARMS, VACANT LAND, ETC # LOCATION DESCRIPTION YR BUILT INTEREST OCCUPANCY USAGE AUTOMOBILES LIST ALL AUTOS OWNED, LEASED FURNISHED F REGULAR USE # YEAR MAKE AND MODEL RECREATIONAL VEHICLES LIST MOTCYCLES, SNOWMOBILES, DUNE BUGGIES, MINIBIKES, ETC # YEAR TYPE, MAKE AND MODEL LIST ALL OWNED, LEASED, CHARTERED FURNISHED F REGULAR USE # YEAR MOT TYPE, MANUFACTURER AND MODEL LENGTH HSE POWER OPERAT INFMATION LIST ALL MEMBERS OF HOUSEHOLD AND ALL OPERATS OF VEHICLES/ AS REQUIRED BY COMPANY # NAME (AS IT APPEARS ON LICENSE) SEX MAR STAT DATE OF BIRTH MAX SPEED DATE LIC DRIVERS LICENSE #/LIC STATE SOCIAL SECURITY # VEHICLE % USE CRAFT % USE WATERS NAVIGATED OTHER EMPLOYMENT APPLICANT'S OCCUPATION APPLICANT'S EMPLOYER NAME AND ADDRESS YRS EMPL CO-APPLICANT'S OCCUPATION CO-APPLICANT'S EMPLOYER NAME AND ADDRESS YRS EMPL PRI EXPERIENCE HAS ANY AUTO ACCIDENT LIABILITY LOSS ON ANY PRIMARY EXCESS POLICY OCCURRED, REGARDLESS OF FAULT, DURING THE LAST YEARS? PRI CARRIER NO YES (PROVIDE OPERAT #, DATE OF LOSS, AND DESCRIPTION) PRI POLICY NUMBER Page 2 of 5

3 GENERAL INFMATION EXPLAIN ALL "YES" RESPONSES 1. ANY AIRCRAFT OWNED, LEASED, CHARTERED FURNISHED F REGULAR USE? Y / N 2. ANY OPERATS CONVICTED F ANY TRAFFIC VIOLATIONS DURING THE LAST THREE (3) YEARS? # OPERAT NAME DATE DESCRIPTION 3. ANY OPERAT HAVE A PHYSICAL/MENTAL IMPAIRMENT? (List operator number) (Not Applicable in WI) ANY SWIMMING POOL, SPA HOT TUB ON PREMISES? IF SWIMMING POOL (Check all that apply): ABOVE GROUND APPROVED FENCE IN GROUND DIVING BOARD ANY REAL ESTATE, VEHICLES,, AIRCRAFT USED COMMERCIALLY F BUSINESS PURPOSES? SLIDE 6. ANY REAL ESTATE, VEHICLES,, AIRCRAFT, OWNED, HIRED, LEASED REGULARLY USED, NOT COVERED BY PRIMARY POLICIES? 7. DO YOU ENGAGE IN ANY TYPE OF FARMING OPERATION? 8. DO YOU HOLD ANY NON-COMPENSATED POSITIONS? ANY EMPLOYEES? EMPLOYEE TYPE # FULL TIME PART TIME WHERE IS WK PERFMED INSIDE OUTSIDE INSIDE OUTSIDE # HOURS PER WEEK DUTIES ANY NON-OWNED PROPERTY EXCEEDING 1,000 IN, IN YOUR CARE, CUSTODY CONTROL? TOTAL PAYROLL ALL EMPLOYEES 11. ANY BUSINESS AND/ PROFESSIONAL ACTIVITIES INCLUDED IN THE PRIMARY POLICIES? 12. DOES ANY PRIMARY POLICY HAVE REDUCED LIMITS OF LIABILITY ELIMINATE COVERAGE F SPECIFIC EXPOSURES? 13. ANY COVERAGE DECLINED, CANCELLED NONREED DURING THE LAST FIVE (5) YEARS? (Not Applicable in MO) 14. DOES APPLICANT ANY TENANT HAVE ANY ANIMALS EXOTIC PETS? ANIMAL TYPE BREED BITE HISTY (Y/N) 15. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY? 16. ANY PENDING LITIGATION, COURT PROCEEDINGS JUDGEMENTS? 17. IS THERE A TRAMPOLINE ON THE PREMISES? SAFETY NET (Y/N): Page 3 of 5

4 REMARKS (Attach additional sheets if more space is required) ATTACHMENTS STATE SUPPLEMENT(S), IF APPLICABLE. BINDER EFFECTIVE DATE TIME INSURANCE BINDER NOON COVERAGE IS NOT BOUND EXPIRATION DATE 12:01 AM IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY: THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION. THIS INSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN USE BY THE COMPANY. THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER BY WRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE. THIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCDANCE WITH THE POLICY CONDITIONS. THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY, THE COMPANY IS ENTITLED TO CHARGE A PREMIUM F THE BINDER ACCDING TO THE RULES AND RATES IN USE BY THE COMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY. APPLICABLE IN COLADO: THE INSURER HAS THIRTY (30) BUSINESS DAYS, COMMENCING FROM THE EFFECTIVE DATE OF COVERAGE, TO EVALUATE THE ISSUANCE OF THE INSURANCE POLICY. Page 4 of 5

5 SIGNATURE PERSONAL INFMATION ABOUT YOU, INCLUDING INFMATION FROM A CREDIT OTHER INVESTIGATIVE REPT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION F INSURANCE AND SUBSEQUENT AMENDMENTS AND REALS. SUCH INFMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFMATION COLLECTED BY US OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHIZATION. CREDIT SCING INFMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY F INSURANCE THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCE. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFMATION IN OUR FILES AND CAN REQUEST CRECTION OF ANY INACCURACIES. A ME DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT BROKER F INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US. Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not applicable in all states, consult your agent or broker for your state's requirements.) ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY ANOTHER PERSON FILES AN APPLICATION F INSURANCE STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFMATION, CONCEALS F THE PURPOSE OF MISLEADING INFMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied) IN FLIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, MISLEADING INFMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. IN MASSACHUSETTS, NEBRASKA, EGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY ANOTHER PERSON FILES AN APPLICATION F INSURANCE STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFMATION, CONCEALS F THE PURPOSE OF MISLEADING INFMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES. APPLICABLE ONLY IN GEGIA, INDIANA, LOUISIANA, HAMPSHIRE, VERMONT AND WISCONSIN IF THE COMPANY TO WHICH I AM APPLYING OFFERS UNINSURED MOTISTS (UM) COVERAGE IN MY STATE: APPLICABLE ONLY IN INDIANA: I ACKNOWLEDGE THAT UM COVERAGE AND UNDERINSURED MOTISTS (UIM) COVERAGE HAVE BEEN EXPLAINED TO ME, AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM AND UIM LIMITS EQUAL TO MY LIABILITY LIMITS, UM AND UIM LIMITS LOWER THAN MY LIABILITY LIMITS, TO REJECT UM AND/ UIM COVERAGE ENTIRELY. 3. I SELECT UIM LIMITS INDICATED IN THIS APPLICATION. APPLICABLE ONLY IN GEGIA AND LOUISIANA: I ACKNOWLEDGE THAT UM COVERAGE HAS BEEN EXPLAINED TO ME, AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM LIMITS EQUAL TO MY LIABILITY LIMITS, UM LIMITS LOWER THAN MY LIABILITY LIMITS, TO REJECT UM COVERAGE ENTIRELY. APPLICABLE ONLY IN HAMPSHIRE: I ACKNOWLEDGE THAT UM COVERAGE HAS BEEN EXPLAINED TO ME, AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM LIMITS EQUAL TO MY LIABILITY LIMITS TO REJECT UM COVERAGE ENTIRELY. 4. I REJECT UIM COVERAGE IN ITS ENTIRETY. APPLICABLE ONLY IN VERMONT: I ACKNOWLEDGE THAT I HAVE BEEN OFFERED UM COVERAGE EQUAL TO MY LIABILITY LIMITS. I HAVE SELECTED THE LIMITS INDICATED IN THIS APPLICATION. APPLICABLE ONLY IN WISCONSIN: UM COVERAGE: IS AVAILABLE IS NOT AVAILABLE UIM COVERAGE: IS AVAILABLE IS NOT AVAILABLE APPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS INFMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY F WHICH I AM APPLYING. APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER Page 5 of 5