Applicant Information
Applicant Name
Entity Type
Has the applicant or any resident of the applicant's household had a liability loss greater than $50,000 in the past 5 years or is there an open liability claim or lawsuit pending against them?
Is a United States Liability Insurance Group company the expiring carrier? (United States Liability Insurance Co., Mt. Vernon Fire Insurance Co., U.S. Underwriters Co. or Mt. Vernon Specialty Insurance Co.)
Is any member of the household a Federal or State Political Figure, Professional Athlete or Coach, Music or Television Entertainer, or CEO of a Fortune 500 Company?
Email Address of Applicant or Applicant primary contact
Primary Location Address
Street Address
Zip
State
City
Underlying Liability
What is the limit of the primary (or underlying) umbrella policy
Personal Umbrella Exposures
Excess Personal Liability
Are any Locations used as rooming houses, student housing, assisted living facilities or group home facilities?
Are the minimum underlying limits for automobiles covered completely by a business auto policy?
Is any of the Required Underlying Insurance, other than Auto or Farm owners Coverage, provided by a commercial general liability policy or coverage form?
Is there an additional insured endorsement required for this risk?
Within the past five (5) years, has the trust engaged in any form of business or owned any real estate for business purposes whether or not identified on the application?
Within the past five (5) years, has the trust been the subject of litigation of any kind?
Does the trust have any employees?
Does the trust own any real estate, personal property or assets not listed on the application?
Is there any Business Exposure operation covered by the Primary Homeowners or Comprehensive Personal Liability Policy?
Does the applicant have any owner occupied secondary residences?
Total number of additional residential units owned and occupied (do not include Primary Residence; a duplex=2 units)
Does the applicant have any 1-4 family residential units rented to others?
Total number of residential units rented to others (count each unit; a duplex=2)
Does the applicant have any automobiles or motor homes licensed for road use in your household?
Total number of Automobiles and Motor Homes owned or regularly used
Does the applicant have any motorcycles, scooters or other vehicles with less than four wheels and licensed for road use in your household?
Total number of Motorcycles, Scooters or Other Vehicles with less than 4 wheels owned or regularly used
Does the applicant have any recreational vehicles (vehicles not licensed for road use)?
Total number of Recreational Vehicles (vehicles not licensed for road use) owned or regularly used
Watercraft Information

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Driver Information (Include all household members age 14 and over)

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