UMBRELLA / EXCESS LIABILITY

Insured Information

Dun & Bradstreet Number

Insured Name

Trade Name

Address

City

State

Zip Code

Total # of employees

Sales / Business Income

Year business established

Website URL

Please describe the insureds operation in detail

Policy Effective Date Requested

Policy Expiration Date Requested

Policy Limit Requested

Are all underlying policies (except EBL) on an Occurrence form

SELECT YES NO

Does the insured have a formal safety program in place? If yes, please forward copy

SELECT YES NO

Are all underlying Auto and General Liabiity policies written with defense costs outside the Limit of Liability and unlimited?

SELECT YES NO

Do you have a separate Garage liability policy?

SELECT YES NO

Do you want to waive Automobile Liability coverage?

SELECT YES NO

Please provide details for the underlying General Liability Policy

Underlying Carrier Name

Policy Number

Does the General Liability include Hired & Non Owned Automobile Coverage

SELECT YES NO

Hired & Non Owned Automobile Limit

Will Hired & Non Owned automobile losses erode any General Liability aggregate

SELECT YES NO

Does insured have employees using their own vehicles on Company business on a regular basis

SELECT YES NO

Is the General Liability policy written with an ISO Form CG0001 or equivalent

SELECT YES NO

Per Occurrence Limit

General Aggregate Limit

Products & Completed Ops Aggregate Limit

Per Project General Aggregate

Per Location General Aggregate Limit

Do the limits above include an excess or umbrella policy

SELECT YES NO

Primary General Liability Premium

Primary General Liability Policy Effective Date

Primary General Liability Policy Expiration Date

Is the primary General Liability written with a deductible which is greater than $25,000

SELECT YES NO

Are there additional General Liability Carriers

SELECT YES NO

Waive Employee Benefits Liability

SELECT YES NO

Waive Liquor Liability Coverage

SELECT YES NO

Waive Employers Liability or has WC act been rejected by insured in any state

SELECT YES NO

Any Misc Coverages such as

Watercraft Liability

SELECT YES NO

Marine Liability

SELECT YES NO

Aircraft Liability

SELECT YES NO

Railroad Liability

SELECT YES NO

Charterers Liability

SELECT YES NO

Wharfingers Liability

SELECT YES NO

Terminal Operators Liability

SELECT YES NO

Druggists Liability

SELECT YES NO

Misc Professional Liability

SELECT YES NO

Other - Please describe

SELECT YES NO

Does the current insurance program include a Lead Umbrella and do you want Excess Liability coverage over Lead Umbrella

SELECT YES NO

General Liability Losses

Automobile Liability Losses

Other Liability Losses

Year

# of Claims

Total $

Valuation Date

Year

# of Claims

Total $

Valuation Date

Year

# of Claims

Total $

Valuation Date

2008

2008

2008

2007

2007

2007

2006

2006

2006

2005

2005

2005

2004

2004

2004

Does the First Named Insured have any ownership interest in other Named Insureds or other subsidiary companies

SELECT YES NO

Please specify what state or states the insureds automobiles are registered or principally garaged in

Automobile Fleet Breakout (including foreign vehicles)

Are there any sales outside of the United States

SELECT YES NO

Does the primary policies contain any sub-limits less that $1,000,000 (other than Medical Payments or Fire Legal)

SELECT YES NO

Please select the applicable sub-limit

Assault & Battery sub-limit

Sexual Molestation

Pollution

Liquor

Other

Does the primary policy have any exclusions not listed above

SELECT YES NO

Is there any additional information you would like to tell us about this insured:

Agency Name:

Agency Address:

Agency Phone:

Agency Fax:

Agency Contact:

Contact E-Mail Address:

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