PERSONAL UMBRELLA APPLICATION

Transcription

1 Home Office: 6 North Carroll Street, Suite 209 Madison, Wisconsin Property/Casualty Division: 8877 North Gainey Center Drive Scottsdale, Arizona Fax (480) PERSONAL UMBRELLA APPLICATION NAME ADDRESS Last First Middle Number & Street City State Zip Producer Producer Code Agt/Brkr Lic.# GARAGING ADDRESS (if different) POLICY PERIOD From: / / To: / / Renews Policy Number Office Address City Tel: Fax: UMBRELLA INFORMATION: COVERAGES PREMIUMS CALCULATIONS Application for Primary Umbrella BASIC $ Application for Excess Umbrella RESIDENCES $ POLICY AMOUNT RETENTION AUTOMOBILES $ RECREATIONAL VEHICLES $ $ MILLION $ WATERCRAFT $ OPTIONAL COVERAGES TO APPLY: PRIMARY POLICY INFORMATION: OTHER $ TOTAL $ TYPE OF POLICY COMPANY/POLICY NUMBER POLICY PERIOD LIMITS OF LIABILITY BODILY INJURY PROPERTY DAMAGE AUTOMOBILE PERSONAL LIABILITY WATERCRAFT RECREATIONAL VEHICLE UNDERLYING UMBRELLA $ MILLION OPERATOR INFORMATION: LIST ALL MEMBERS OF HOUSEHOLD AND ALL OPERATORS OF VEHICLES/WATERCRAFT AS REQUIRED BY COMPANY # NAME REAL ESTATE: DRIVERS LICENSE NUMBER STATE DATE OF BIRTH VEHICLE, CRAFT, % USE, ETC. MIR VIOL. 3 YEARS MAJOR VIOL. 3 YEARS ACCO 3 YEARS LIST ALL OWNED, LEASED OR OCCUPIED RESIDENCES, BUILDINGS, FARMS, VACANT LAND, ETC. # LOCATION DESCRIPTION # UNITS/ACRES YEAR BUILT OCCUPANCY 2 3 PUMBAPP (0-00) Page of 3

2 AUTOMOBILES: LIST ALL AUTOS OWNED, LEASED RECREATIONAL VEHICLES: LIST MOTORCYCLES, SWMOBILES, DUNE BUGGIES, MINIBIKES, ETC. # YEAR MAKE & MODEL # YEAR MAKE & MODEL WATERCRAFT: LIST ALL WATERCRAFT OWNED, LEASED, CHARTERED OR FURNISHED FOR REGULAR USE # YEAR TYPE, MANUFACTURER, MODEL LGTH. H.P. MAX SPEED FT. 2 FT. EMPLOYMENT: OCCUPATION SPOUSE S OCCUPATION OTHER OPERATOR S OCCUPATIONS PRIOR EXPERIENCE EMPLOYER S NAME & ADDRESS COST NEW EMPLOYER S NAME & ADDRESS (If not employed, so indicate) EMPLOYER S NAME & ADDRESS (If not employed, so indicate) HAS ANY LOSS OCCURRED ON ANY PRIMARY OR EXCESS POLICY, EXCEEDING $5,000, DURING THE LAST 5 YEARS? YES (Explain) CUR. VALUE PRIOR CARRIER & POLICY.? WATERS NAVIGATED GENERAL INFORMATION: # EXPLAIN ALL YES RESPONSES IN REMARKS YES # EXPLAIN ALL YES RESPONSES IN REMARKS YES Any aircraft owned, leased, chartered or furnished for regular use? 2 Any driver convicted for any traffic violations? (Last 3 years) 9 3 Any driver with mental/physical impairments? Any premises, vehicles, watercraft, aircraft used for business? Any premises, vehicles, watercraft, aircraft, owned, hired, leased or regularly used, not covered by primary policies? 8 Do you employ any residence employees? 2 6 Do you engage in any type of farming operation? 3 7 Do you hold any non-remunerative positions? 4 REMARKS: 5 Any non-owned property exceeding $,000 in value, in your care, custody or control? Any non-owned business and/or professional activities included in the primary policies? Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures? Was any coverage declined, cancelled, nonrenewed? (Last 5 years) (Not Applicable to Missouri Applicants) Any motorcycles, mopeds or all terrain vehicles owned by insured (may be excluded)? Any other underwriting information of which Company should be aware? Are any business activities conducted from your residence or premises (excluded in policy jacket)? TICE TO APPLICANT: In compliance with Public Law 9-8, this notice is to inform you that in connection with your application for insurance () an investigation may be made as to your insurability, including information as to character, general reputation, personal characteristics and mode of living; and (2) additional information as to the nature and scope of any investigation requested will be furnished to you, upon your written request made within a reasonable time after you receive this notice. I have read the foregoing and agree that it is true and complete to the best of my knowledge and that this policy, if issued, and all renewals thereof, are to be issued in reliance upon this information, unless a change in information is supplied by me. I understand that signing this application does not bind me to accept this insurance nor does it bind the company to issue a policy to me. PRIVACY POLICY: I have received and read a copy of the National Casualty Company Privacy Statement and Procedures. By submitting this application, I am applying for issuance of a policy of insurance and, at its expiration, for appropriate renewal policies issued by National Casualty Company and/or other members of the Scottsdale group of insurance companies. I understand and agree that any information about me that is contained in, or that is obtained in connection with, this application or any policy issued to me may be used by any company within the Scottsdale group to issue, review, and renew the insurance for which I am applying. PUMBAPP (0-00) Page 2 of 3

3 APPLICABLE IN THE STATE OF NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. INSURANCE CANT BE CONSIDERED FOR BINDING UNLESS THIS APPLICATION IS SIGNED BY THE APPLI- CANT: Applicant Signature X Time: Date: Agent/Broker Signature X Date: PUMBAPP (0-00) Page 3 of 3

4 A& M Personal Umbrella Rating Worksheet- National Casualty rates National Casualty writes in all states except the following: Connecticut, Louisiana & New York (Connecticut and Louisiana quotes available through our other umbrella market) For all New Jersey risks:.9% surcharge to be applied for the NJGA fee Florida risks:.3% surcharge for the Hurricane Relief Fund $ million max limit in the following states: IN, NH, VT, WV Additional UM coverage of $ mil can be purchased for $.00 in all states except in IN, NH, VT where charge is $00.00 per vehicle RATE: ML 2 ML 3 ML 4 ML 5 ML BASIC INCLUDES: ( house/2 vehicles) ADDITIONAL S EACH ADT L VEHICLE EACH SECONDARY RESIDENCE EACH YOUTHFUL DRIVER (UNDER 22) EACH DRIVER 76 AND OVER LOWER AUTO LIMITS 0/0/00 OR 300/0/00 DRIVERS UNDER 22 OR 76 & OVER 0/0/00 OR 300/0/ MOTORHOMES RENTAL UNITS (PER UNIT, 8 MAX) VACANT LAND 0- ACRES ACRES ACRES ACRES OVER 300 ACRES FARMS (COVERS UP TO 300 ACRES) WATERCRAFT UP TO 00 HP TO HP TO 200 HP TO 300 HP TO 400 HP TO 0 HP OVER 0 HP (OVER 300 HP, REFER TO CO) SAILBOAT AND HIGHER POLICY FEE ( no fee in FL,HI,IA,IN, KS,KY,MD,MO,MT,NJ,NM,SC,TX,WV) ADDT L UM (SEE TOP OF PAGE) DRIVER SUR (PER HOUSEHOLD IN PAST 36 MONTHS) FIRST 3 MOVING CONVICTIONS EACH ADT L MOVING CONVICTION FIRST ABLE ACCIDENT EACH ADT L ABLE ACCIDENT FIRST MAJOR CONVICTION PAST 36 MONTHS ONE MAJOR CONVICTION PLUS ANY MOVING CONVICTION (REFER TO COMPANY) 2 ND MAJOR IN 60 MONTHS (REFER TO CO) RD MAJOR IN 60 MONTHS (REFER TO CO)

5 National Casualty Personal Umbrella Rules & Rates ** NEW JERSEY RISKS- apply.9% surcharge for NJGA fee **MASSACHUSETTS RISKS- DRIVERS OVER MUST HAVE AUTO LIMITS OF AT LEAST 0/0/00 OR 0 CSL **WE DO T WRITE IN THE FOLLOWING STATES: CT, LA, NY **WE ONLY OFFER $ MILLION LIMIT IN THE FOLLOWING STATES: NH, VT, WV. MIL UM available in these states only. $3-0 million umbrellas available upon request. Please contact Anderson & Murison UMBRELLA WRITTEN THROUGH NATIONAL CASUALTY (ADMITTED, A+ RATED) $ Million $2 Million Basic Charge(includes primary residence and two automobiles) $98 $358 Additional Premium Charges: Secondary Residence Additional Automobiles including snowmobiles, ATVS, motorcycles (each) Lower Liability s Option (0,000/0,000/00,000 OR 300/0/00) Drivers under 22 or 76 & older with lower auto limits of 0/0/00 or 300/0/00 (must have good driving records) Recreational Vehicle (motorhome) Rental Units (each Unit) Maximum 8 Rental Units (e.g. Triplex plus 5 Unit Apt.= 8 Units) Must carry Personal Injury Liability on the primary general liability policy. Watercraft (MUST T EXCEED 40MPH MAX SPEED. MAY BE ACCEPTED WITH NATIONAL CASUALTY S PRIOR APPROVAL} 00 HP and Under 0 HP to HP to 200 HP 20 HP to 300 HP 30 HP to 400 HP 40 HP to 0 HP over 0 HP (SUR 0 HP RATE %) **over 300hp, please refer to company Sailboats 0- feet 26 feet and larger Youthful Drivers Under Age 22 (each) Drivers 76 years of age and older (each) Premium Total* Policy Fee (EXCEPT for AK,FL,HI,IA,IN,KS,KY,MD,MO,NM,NJ,SC,TX,WV Self-Retention Driver surcharge PER HOUSEHOLD $ Million $2 Million First 3 moving convictions in past 36 months Each additional moving conviction in past 36 months per household First chargeable accident past 36 months Each additional chargeable accident per household in past 36 months--- surcharge per accident. First major conviction past 36 months. One () major conviction plus any moving conviction (refer to company)

6 ..Anderson & Murison personal umbrella rates continued 2 Underlying Coverage Needed Type of Policy Comprehensive Personal Liability Automobile/Recreational Vehicle Watercraft Rental Units ALL UNDERLYING CARRIERS MUST BE RATED B+ OR BETTER IN BEST S GUIDE Minimum s Required 300,000 combined single limit 0,000 combined single limit or 0,000/0,000 bodily injury 00,000 property damage or for additional premium charge 0,000/0,000 bodily injury 00,000 property damage (see exceptions below under "Driving Record) 0,000 combined single limit or 0,000/0,000 bodily injury 00,000 property damage ***$300,000 is acceptable when there are no youthful drivers on policy 300,000 combined single limit (must include personal injury coverage) Other Exposures Either Excluded or Subject to Approval. Please call for farm and vacant land charges. Vacant land is subject to underwriting approval (please call for rates). Farm exposures subject to underwriting approval (please call for rates). Prior Liability Claims Insured cannot have more than one liability claim (auto or personal) in five years that exceeds $5,000. Ineligible Risks: Aircraft are not covered Drivers with alcohol-related violations within the last year Vehicles covered by underlying policies cannot have been modified, other than the factory Business pursuits including policies written in corporate name. No underlying CPL Risks with commercial underlying policies OL&T s are acceptable. houseboats are not covered. Youthful drivers with alcohol-related violations. Automobiles: First two vehicles included in base premium No limit on number of vehicles. Corporate vehicles are unacceptable UNLESS insured is sole proprietor. Driving Record: Surcharges apply per HOUSEHOLD not per driver (as in past years) Surcharges apply per household instead of per driver Surcharge added for more than accident per household Surcharge added for more than 3 convictions per household Surcharge added for major conviction Individual driver cannot have more than three moving violations in past 3 years Individual driver cannot have more than one at-fault accident in past 3 years To qualify for the lower liability limit options, drivers must qualify as "good drivers" (no more than 2 convictions). In order for youthful drivers to qualify for the lower limits, they must have no more than minor violation on their driving record. All other youthful drivers require the 0,000/0,000/00,00 limits. Please refer to company for the following risks: Farms Drivers over 70 years of age with driving activity in the past 3 years Vacant land Target risks (Entertainment, Sports and Political personalities. May include highly visible professional or business personalities. Applicants who have had more than one liability claim that exceeds $5,000 in payment during the last 5 years.