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.   Applicant Name Mailing Adress   City State Zip Code Policy Period From:   To: Renews Policy Number UMBRELLA INFORMATION COVERAGE PREMIUMS Application for Primary Umbrella Application for Excess Umbrella POLICY AMOUNT RETENTION $  Million $ OPTIONAL COVERAGES TO APPLY Basic $ Residences $ Automobiles $ Recreational Vehicles $ Watercraft $ Other $ Total $ PRIMARY POLICY INFORMATION TYPE OF POLICY COMPANY/POLICY NUMBER POLICY PERIOD LIMITS OF LIABILITY BODILY INJURY                          PROPERTY DAMAGE AUTOMOBILE PERSONAL LIABILITY WATERCRAFT RECREATIONAL VEHICLE UNDERLYING UMBRELLA $    MILLION OPERATOR INFORMATION LIST ALL MEMBERS OF THE HOUSEHOLD AND ALL OPERATORS OF VEHICLES/WATERCRAFT AS REQUIRED BY COMPANY   # NAME DRIVERS LICENSE NUMBER STATE DATE OF  BIRTH VEHICLE, CRAFT, % OF USE, ETC. MINOR VIOL. (3 YEARS) MAJOR VIOL. (3 YEARS) ACCIDENT (3 YEARS) 1 2 3 4 REAL ESTATE LIST ALL OWNED, LEASED OR OCCUPIED RESIDENCES, BUILDINGS, FARMS, VACANT LAND, ETC. # LOCATION DESCRIPTION # UNITS/ACRES YEAR BUILT OCCUPANCY 1 2 3 AUTOMOBILES                                                              RECREATIONAL VEHICLES LIST ALL AUTOS OWNED, LEASED # YEAR MAKE AND MODEL 1. 2. 3. LIST MOTORCYCLES, SNOWMOBILES, DUNE BUGGIES, MINIBIKES, ETC. # YEAR MAKE AND MODEL 1. 2. 3. WATERCRAFT   LIST ALL WATERCRAFT OWNED, LEASED, CHARTERED OR FURNISHED FOR REGULAR USE # YEAR TYPE, MANUFACTURER, MODEL LENGTH H.P. MAX SPEED COST NEW CURR.VALUE WATERS NAVIGATED 1 2 EMPLOYMENT OCCUPATION EMPLOYER'S NAME AND ADDRESS SPOUSE'S OCCUPATION EMPLOYER'S NAME AND ADDRESS OTHER OPERATOR'S OCCUPATION EMPLOYER'S NAME AND ADDRESS PRIOR EXPERIENCE HAS ANY LOSS OCCURRED ON ANY PRIMARY OR EXCESS POLICY, EXCEEDING $5,000.00 DURING THE LAST 5 YEARS? YesNo PRIOR CARRIER AND POLICY NUMBER 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? YesNo 8 Do you employ any residence employees? YesNo 2 Any driver convicted for any traffic violations?(Last 3 years) YesNo 9 Any non-owned property exceeding $1,000.00 in value in your care, custody or control? YesNo 3 Any driver with mental/physical impairments? YesNo 10 Any non-owned business and/or professional activities included in the primary policies? YesNo 4 Any premises, vehicles, watercraft, aircraft used for business? YesNo 11 Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures? YesNo 5 Any premises, vehicles, watercraft, aircraft, owned, hired, leased or regularly used, not covered by primary policies? YesNo 12 Was any coverage declined, cancelled, non-renewed? (Last 5 years) YesNo 6 Do you engage in any type of farming operation? YesNo 13 Any motorcycles, mopeds or all terrain vehicles owned by the insured? (May be excluded) YesNo 7 Do you hold any non-remunerative positions? YesNo 14 Any other underwriting information of which Company should be aware? YesNo       15 Are any business activities conducted from your residence or premises (excluded in policy jacket)? YesNo Remarks   Producer Name Contact Person Phone Number  FAX Number: Email Address         (You will get a summary page to review before submitting)