Premier Services - The Insurance Experts

Umbrella Insurance Application
(Quotes will be provided for Pennsylvania, New Jersey, New York, Maryland and Delaware)

Most insurance companies offer their umbrella policy only as a package with their home insurance policy. Please complete our Home Insurance Form so we can also quote your home coverage.

Contact name:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Applicant occupation:

Spouse occupation:

Underlying liability

Home: do you have at least $300,000?: Yes No

Dwellings: do you have at least $300,000 on all other dwellings?: Yes No

Auto: do you have at least $500,000 CSL or $250,000/$500,000/100 split? Yes No

Recreational vehicles: do you have at least $500,000 CSL or $250,000/$500,000/100 split? Yes No

Watercraft: do you have at least $300,000 CSL? Yes No

Real estate information

Location #1 address:

City:

State

Zip:

Type:

Is this property:

Number of units:

Description:

Location #2 address:

City:

State

Zip:

Type:

Is this property:

Number of units:

Description:

Location #3 address:

City:

State

Zip:

Type:

Is this property:

Number of units:

Description:

Driver information

Driver #1 name:

Age:

Marital status:

Sex:

Years licensed:

License number:

Violations/accidents (list dates, details):

Driver #2 name:

Age:

Marital status:

Sex:

Years licensed:

License number:

Violations/accidents (list dates, details):

Driver #3 name:

Age:

Marital status:

Sex:

Years licensed:

License number:

Violations/accidents (list dates, details):

Driver #4 name:

Age:

Marital status:

Sex:

Years licensed:

License number:

Violations/accidents (list dates, details):

Vehicle information

Vehicle 1 make:

Model:

Year:

Vehicle 2 make:

Model:

Year:

Vehicle 3 make:

Model:

Year:

Vehicle 4 make:

Model:

Year:

Recreational vehicle(s):
Includes motorcycles, snowmobiles, dunebuggies, etc.

Vehicle 1 make:

Model:

Year:

Type:

Vehicle 2 make:

Model:

Year:

Type:

Vehicle 3 make:

Model:

Year:

Type:

Watercraft

Boat #1 make:

Year:

Length:

Horsepower:

Maximum speed:

Drive:

Boat #2 make:

Year:

Length:

Horsepower:

Maximum speed:

Drive:

General information

Do you have a swimming pool with a fence? Yes No

Any dangerous hobbies? Yes No

If you answered yes to the above, please describe:

Do you own or lease an aircraft? Yes No

Do you have any dogs, horses or livestock on the property? Yes No

If you answered yes to the above, please describe type of animals:

Current insurance carrier:

Effective date:

Premium paid:

Please explain any claims against you in the past five years. Please include date, amount of claim, and details:

Would you like a quote from us for the same coverage for easy comparison? Yes No

Do you have quotations from other companies? Yes No

Who is the insurance company?

What was the price quoted?

How did you hear about us?

Additional Comments: