Commercial Umbrella Liability Insurance

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Commercial Umbrella Liability Insurance Quote Request Form

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

Named Insured:

General Information:

* Business Name

Type of Business :

*Contract - Full Name:

Describe Operations :

* Title / Position:

Business Model:

* Employers Federal Tax Id # (FEIN)

Select Any Other Kinds Of Coverage Below That You Need Quoted:

*Contact Phone:

Cell #

Building / Contents / Liability

Business Owners Policy :

Flood Insurance :

Workers Comp: Fidelity/Surety Bond

*Fax:

Commercial Auto: Cargo / Freight

Heavy Equipment Cargo ( Inland/Ocean)

Web Site Address:

Umbrella Liability: Professional Liability :

Other - Please specify or describe:

*Email:

*Send Quick Quote By : Email Fax Both

Current Insurance Carriers Name :

Policy Number

Expiration Date:

*Business Address:

Address:

City:

State: Zip :

County:

Mailing Address: Same as Mailing Address
Address:

City :

State: Zip:

County :

Business Information:

Years in Business:		Total Number of Employees:	Employees : # Full Time: # Part Time:
Approx. Annual Gross Sales / Revenue $		Approx. Annual Payroll $

Umbrella Liability Coverage Type & Limits Requested:

Select Policy Type: Claims Made - Covers claims submitted from retroactive date & reported while policy is in force or any extended reporting period (if applicable ).

Occurrence -Only covers claims incurred during the policy period.

*Umbrella Policy Liability Limit $

Limit Per Each Occurrence

Aggregate Limit All Claims

Requested Effective Date

1st Dollar Defense Coverage Requested:

Yes No

* Amount of Self Insured Retained Limit Before Any Claim Payments Begin ( a retained limit is very similar to a deductible under other type insurance policies ) $

If Claims Made Policy - Please Provide Policy Retroactive Date With Effective Date Shown On Current Policy And Any Other Date You Wish To Propose.

Current

Proposed

CURRENTLY IN FORCE BASIC (UNDERLYING) LIABILITY INSURANCE COVERAGE In Force Policy Information:

List All Liability Insurance Policies For Which Your Firm Currently Has In Force Underlying Liability Insurance Protection

Type

Insurance Company

Policy Number

Effective Date

Expiration Date

Coverage Limits

Annual Premium

Claims Experience

Rating Modifier

( If Applicable)

Automobile Liability

Bodily Injury Per Person	$
Bodily Injury Per Accident	$
Property Damage Per Accident	$
Or -Combined Single Limit	$

Underlying Auto Liability Vehicle Information ( Explain All " Yes" responses in remarks/comments section at bottom of this page ).

VEHICLES

Type		# Owned	# Non-Owned	# Leased	Property Hauled	# Operating Within 0-50 Miles	# Operating Within 50-200 Miles	# Operating Over 200 Miles
Private Passenger
Trucks	Light GVW <10,000
	Medium GVW 10,000 to 20,000
	Heavy GVW 20,001 to 45,000
	Ex. Heavy GVW 45,000+
Trucks/Tractors	Heavy GVW 20,001 to 45,000
Trucks/Tractors	Ex. Heavy GVW 45,000+
Buses

1. Are any explosives, caustics , flammables or other dangerous cargo hauled ? YesNo 2. Are passengers carrier for a fee ? YesNo 3. Any any vehicles not insured under underlying auto policy ? YesNo 4. Are any vehicles leased or rented to others ? YesNo 5. Is hired and non-owned coverage provided under underlying commercial auto policy ? YesNo 6. Employees use their own vehicles on company business ? YesN

General Liability

Claims Made Occurrence

Per Occurrence Limit	$
Aggregate Limit All Claims	$
Product / Completed Operations Aggregate Limit	$
Personal & Advertising Injury	$
Damage To Rented Premises	$
Medical Expense (Per Person With No Fault Required)	$

General Liability $

Product/Com Ops $

All Other General Liability Premiums $

Underlying General Liability Information ( Explain All " Yes" responses in remarks/comments section at bottom of this page ).

Defense Cost Are : Included within aggregate limits A separate limit Unlimited Has any product, work, accident, or location been excluded, uninsured or self insured from any previous general liability policy ? Yes No If prior general liability policy was issued as a Claims Made Policy has any extended reporting period coverage been purchased at policy expiration ? Yes No

Employers Liability

(Workers Comp)

Each Accident	$
Disease Each Employee	$
Disease Policy Limit	$

Employers Liability Workers Comp Prem. $

Underlying Employer Liability / Workers Compensation Information ( Explain All " Yes" responses in remarks/comments section at bottom of this page ).

Is your firm self-insured for Employer Liability / Workers Compensation in any state ? Yes No Check Box If Your Firm Is Subject To : Jones Act - US Longshoremen & Harbors workers Maritime Employers Act Federal Employers Liability Act

Professional Liability

Per Occurrence Limit	$
Aggregate Limit All Claims	$

Professional Liability $

Underlying Professional Liability Information ( Explain All " Yes" responses in remarks/comments section at bottom of this page ).

Claims Made - Covers claims submitted from retroactive date & reported while policy is in force or any extended reporting period (if applicable ).

Occurrence -Only covers claims incurred during the policy period.

Defense Cost Are : Included within aggregate limits A separate limit Unlimited Has any product, work, accident, or location been excluded, uninsured or self insured from previous professional liability policy ? Yes No If prior general liability policy was issued as a Claims Made Policy has any extended reporting period coverage been purchased at policy expiration ? Yes No

List Any Other Liability Insurance - Name Type:

Per Occurrence Limit	$
Aggregate Limit All Claims	$

Any Other Liability Insurance Premium $

Check Applicable Box(s) If Your Firms Has Any Exposure To The Following Type Risks :

Aircraft Liability - Rental or Operation	Medical Malpractice - including but not limited to incidental risk exposure
Aircraft Passenger Liability	Liquor Liability - including but not limited to host liquor liability associated with client entertainment company sponsored parties or other functions
Additional Interests - Endorsement Naming Another Party As An Additional Insured Under Your Umbrella Policy Per A Written Contract Requiring Such Coverage.	Pollution Liability
Care, Custody, or Control - Your firm has any exposures for the property belonging to others	Vendors Liability
Employee Benefit Liability - Does your firm offer employees any employee benefit programs such as 401K retirement plan ; group life/health/dental/vision plan.	Watercraft Liability
Foreign Liability / Travel	Other - Describe Nature Of Liability Risk
Garagekeepers Liability - Auto Repair Shops , Auto Sales , and/ or Valet Parking Of Any Nature	Other - Describe Nature Of Liability Risk

Loss History Information:

Most Of Our Insurance Company Underwriters Require Prior Carrier Generated Loss History Reports For Last 5 Years Prior To Binding Coverage.

*Has your business had any losses or filed a claim in the last five (5) years? YesNo

If "Yes" Please Briefly Provide Details ( amount paid / carrier / policy # / date of loss or claim / nature of claim / pending or settled)

Additional Comments/Remarks You Wish Us To Consider When Preparing Your Quote:

Submission of quote request form to Hemphill Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage. To confirm binding or current policy revisions you must receive a written confirmation for any new or change in coverage from our agency staff.

Submitting Agent/ Producer - Name: Tel: Email: