BUSINESS
OWNERS PROGRAM
Umbrella Quote Request
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1 |
Contact Information
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Name of Business |
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Contact Name: |
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Address: |
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Address 2: |
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City - St - Zip: |
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Phone Number: |
FAX |
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E-Mail Address: |
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| 2 |
:Desired Limits:
(Each Occurrence / Policy Aggregate) (other limits may be available
upon request)
$1,000,000/$1,000,000 |
$2,000,000/$2,000,000 |
$3,000,000/$3,000,000 |
$4,000,000/$4,000,00 |
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3 |
Desired Self-Insured Retention: |
None
$10,000
other
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4 |
Current Underlying
Insurance Information Please complete the table below with the
information from your current underlying Automobile and Employers’
Liability policies. |
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| 5 |
Is the business self-insured
for Workers’ Compensation or Employers’ Liability in any states?
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YES
NO
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| 6 |
Is the business
subject to any of the following Workers’ Compensation laws?
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7 |
| Has any product, work, accident,
or location been excluded, uninsured or self-insured from any previous
coverage? |
YES
NO
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| If yes, provide details |
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| 8 |
Are any explosives, caustics,
flammables or other dangerous cargo hauled? |
YES
NO
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9
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Are any passengers transported
for a fee? |
YES
NO
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10 |
Are there any autos that
are not insured by an underlying policy? |
YES
NO
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| 11 |
Are any vehicles leased or
rented to others? |
YES
NO
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12 |
Is Hired and Non-owned Auto
coverage on an underlying auto policy?
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YES
NO
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| 13 |
What is the auto liability
coverage symbol on the underlying auto policy? |
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| (This information
can be found on your current auto policy’s Declarations Page.) |
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| 14 |
Vehicles Used or Owned: |
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| 15 |
Does the business own or
use any Buses, or Heavy or Extra Heavy Trucks and/or Tractors? |
YES
NO
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| If yes, please describe the
vehicles and what they are used for. |
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