Step One:
|
Complete Form
|
Step Two:
|
Review and Submit
|
Step Three:
|
Finish
|
|
__________
|
[Form Version: 1.0]
[Updated: 06/04/08]
|
__________
|
|
Welcome to
Personal Umbrella Application from A&M.
|
|
For fast service on your umbrella accounts - complete the form below and
hit the “Step Two” button.
Your submission will be electronically delivered to the next available Umbrella
Underwriter.
Please note: In order to complete the application process, the Commercial Umbrella Supplemental Application must be completed
to schedule your client’s business exposures.
|
|
|
|
|
|
|
UMBRELLA INFORMATION
|
|
PRIMARY POLICY INFORMATION
|
|
OPERATOR INFORMATION
|
LIST ALL MEMBERS OF THE HOUSEHOLD AND ALL OPERATORS OF VEHICLES/WATERCRAFT AS REQUIRED
BY COMPANY
|
|
|
REAL ESTATE
|
|
AUTOMOBILES
RECREATIONAL VEHICLES
|
|
WATERCRAFT
|
|
EMPLOYMENT
|
|
GENERAL INFORMATION
|
#
|
EXPLAIN ALL ""YES"" RESPONSES IN REMARKS
|
|
|
#
|
EXPLAIN ALL ""YES"" RESPONSES IN REMARKS
|
|
1
|
Any aircraft owned, leased, chartered or furnished for regular use?
|
|
8
|
Do you employ any residence employees?
|
|
2
|
Any driver convicted for any traffic violations?(Last 3 years)
|
|
9
|
Any non-owned property exceeding $1,000.00 in value in your care,
custody or control?
|
|
3
|
Any driver with mental/physical impairments?
|
|
10
|
Any non-owned business and/or professional activities included
in the primary policies?
|
|
4
|
Any premises, vehicles, watercraft, aircraft used for business?
|
|
11
|
Does any primary policy have reduced limits of liability or eliminate
coverage for specific exposures?
|
|
5
|
Any premises, vehicles, watercraft, aircraft, owned, hired,
leased or regularly used, not covered by primary policies?
|
|
12
|
Was any coverage declined, cancelled, non-renewed? (Last 5 years)
|
|
6
|
Do you engage in any type of farming operation?
|
|
13
|
Any motorcycles, mopeds or all terrain vehicles owned by
the insured? (May be excluded)
|
|
7
|
Do you hold any non-remunerative positions?
|
|
14
|
Any other underwriting information of which Company should be aware?
|
|
|
|
|
15
|
Are any business activities conducted from your residence or
premises (excluded in policy jacket)?
|
|
|
Remarks
|
|
|
|
|
|
|
|
(You will get a summary page
to review before submitting)
|
|
|
|