Commercial Umbrella Application
This is an "occurrence" policy application. "Claims made" underyling policies are prohibited.
 Contact Information

 Name
 Business Name
 Email Address
 Mailing Address
 Mailing Address
 City, State, Zip
 Phone Numbers  Home   Work 
    Fax   
How would you prefer to be contacted regarding your quote?   
If you would prefer to be contacted by phone, please let us know the best time to call:   
1
Name of applicant and all affiliated companies
 
Name of applicant and all affiliated companies continued
 
2
Location Address/Property Address  
City - St - Zip   
3
Any Foreign Operations? Yes No
If yes to question 3 please indicate where.
4
Give complete description of the applicants operations.
 
5
Annual Sales or Gross Receipts
Payroll
Number of Employees
Years in Business
 Coverage Information
6
Limit of Liability Requested    
If other, Please list here

In excess of primary or self insured retention.
7
Has Applicant previously carried Umbrella or Excess coverage? Yes No
If yes, give name of Insurer, Policy Number, Limits of Liability, and Expiration Date.
8
Has any insurer rejected, cancelled, or refused renewal of any Umbrella or Excess Coverage? Yes No
If yes, give name of Carrier & Reason.
 Premises - Operations
11
Construction of Bldg. is:
  Fire Resistive %
  Masonry/Block %
  Frame or Brick Veneer %
12
Date Built?
  No. of Stories
  No. of Elevators
13
Part Occupied by Applicant: Interest:
14
Describe Business of Tenant if applicable
 
15
Applicant's exposure basis for policy rating:
Total Floor Area:
Parking Area:
No. of Units:
Receipts other than room rental:
Persons
Admissions
Other
16

Does Applicant maintain a Pool, Lake, or Bathing Beach? Yes No
If yes, describe security (fencing, life guards, etc.)
17

Does Applicant or Tenant handle, use or store chemicals? Yes No

Does Applicant have underground storage tanks or premises owned or leased? Yes No

Is Applicant aware of any prior use or storage of any chemicals on premises owned or leased? Yes No

If yes to any of these questions, describe

18

Any Owned Autos? Yes No
If yes how many
Autos used for