Personal Umbrella

Personal Umbrella Insurance Quote

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Contact Information

Full Name

Phone Number

Address

Fax Number

City

Email Address

State

Zip Code

Garaging Address (if different):

Contact me by

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Umbrella Coverages

Policy Amount?

ID Theft Coverage?

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Premiums

Basic

Residences

Automobiles

Recreational Vehicles

Watercraft

Other

Total

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Operator Information

Operator 1 Name

TX Driver's License Number

DOB

3 Year Driving History

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Operator 2 Name

TX Driver's License Number

DOB

3 Year Driving History

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Operator 3 Name

TX Driver's License Number

DOB

3 Year Driving History

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Operator 4 Name

TX Driver's License Number

DOB

3 Year Driving History

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Employment

Occupation

Employer

Spouse's/Other's Occupation

Employer

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Real Estate: List all owned, leased, or occupied residences, buildings, farms, vacant land, etc.

Location/Address 1

# Units/Acres

Underlying Carrier

Underlying Limit

Occupancy Type

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Location/Address 2

# Units/Acres

Underlying Carrier

Underlying Limit

Occupancy Type

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Location/Address 3

# Units/Acres

Underlying Carrier

Underlying Limit

Occupancy Type

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Automobiles and Recreational Vehicles: List all owned or leased automobiles, motorhomes, motorcycles, snowmobiles, dune buggies, minibikes, golfcarts, etc.

Vehicle 1 Year, Make and Model

Vehicle Type

Underlying Carrier

Underlying Liability Limits

Underlying UM/UIM Limits

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Vehicle 2 Year, Make and Model

Vehicle Type

Underlying Carrier

Underlying Liability Limits

Underlying UM/UIM Limits

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Vehicle 3 Year, Make and Model

Vehicle Type

Underlying Carrier

Underlying Liability Limits

Underlying UM/UIM Limits

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Watercraft: List all watercraft owned, leased, chartered or furnished for regular use

Watercraft 1 Year

Type, Manufacturer, Model

Length (in feet)

H.P.

Max Speed

Underlying Carrier

Underlying Liability Limits

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Watercraft 2 Year

Type, Manufacturer, Model

Length (in feet)

H.P.

Max Speed

Underlying Carrier

Underlying Liability Limits

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Prior Experience

Prior Carrier and Policy #

Any pending litigation, open or closed claim on any primary or excess policy, exceeding $25,000 during the last 5 years?

If Yes - please explain

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General Information: Explain all "Yes" responses in Remarks

Any aircraft owned, leased, chartered or furnished for regular use? (excluded in policy jacket)

Any driver convicted for any traffic violations? (Last 3 years)

Any driver with mental/physical impairments?

Any premises, vehicles, watercraft, aircraft used for business?

Any premises, vehicles (including motorcycles, mopeds, ATVs) watercraft, owned, hired, leased or regularly used, not covered by primary policies?

Do you employ any residence employees?

Any applicant convicted of insurance fraud (ineligible) or a Felony (referral)?

Any applicant considered a high profile risk such as politicians, entertainers and professional athletes? (Referral)

Any locations owned by an LLC or Trust?

Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?

Was any coverage declined, cancelled, non-renewed? (Last 5 years)

Any non-owned business and/or professional activities included in the primary policies?

Are any business activities (including daycare) conducted from your residence or premises (excluded in policy jacket)?

Any animals in the household? Please list below including breed, bite history, fighting or security training, if applicable.

Any land used for hunting?

Any swimming pools? Please specify fenced or unfenced, diving boards or slides.

Any excluded drivers on the primary policy?

Any other underwriting information of which we should be aware?

Do you hold any non-remunerative positions?

Remarks

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Named Insured / Additional Insured Supplemental Questions

These questions must be completed when the Named Insured or Additional Insured is a Limited Liability Company (LLC), Trust or Estate.

Name(s):

Entity Name

Entity Mailing Address:

Type of Entity

List all Entity Members, Trustees or Executors

Purpose of the formation of the entity

Has the purpose of the entity changes since its formation?

Within the past 5 years, has the entity engaged in any form of business or owned any real estate for business purposes whether or not identified on the application?

In the past 5 years, has the entity been subject of any kind of litigation?

Does the entity have any employees?

Does the entity own any rel estate, personal property or assets not listed on the application?

Please explain any "Yes" answers

List all exposures owned, in whole or in part, by this entity, the percentage owned, and the usage/occupancy:

Questions or Comments

Personal Umbrella Insurance Quote

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512-451-7867

5353 Williams Drive #118 Georgetown, TX 78633

questions@geneholt.com