Personal Umbrella Insurance Application

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.



General Info
   Name:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
  Email Address:  
Best Time To Contact:
Contact By:

 Agent Information
Applicant's Agent License Number:
Requested Effective Date:
Premium:
Coverage Limit Desired:

Questions
Please carefully read the following questions and respond by entering the appropriate number that applies.
1.   How many motorized vehicles licensed for road use (i.e., motorhomes, motorcycles, cars, etc.) are owned, leased, or regularly operated by you or any member of your household? Include company vehicles provided for your use, or for use by a member of your household. All vehicles licensed for road use need to be counted regardless of individual insurance. (Do not count antique/classic/ collectible vehicles covered under a collector automobile policy.)
2.  How many residential properties are owned or rented by you or any member of your household?
3.  How many watercraft, other than canoes and jetskis, waverunners or other personal watercraft, are owned or regularly operated by you or any member of your household? Count only those watercraft between 14 and 45 feet and with a maximum speed less than 51 mph. Watercraft exceeding these limitations are excluded from coverage.
4.  How many jetskis, waverunners or other personal watercraft are owned or regularly operated by you or any member of your household ?
5.  What is the number of drivers ?
6.  How many drivers are under the age of 22?
7.  How many drivers are age 70 and over ?
8.  How many moving violations have all drivers had within the last 3 years ?
9.  How many at fault accidents have all drivers had in the last 3 years? At fault accident includes any single or multi-car accident chargeable under the primary auto policy, any accident resulting in third party liability payment (BI or PD), any single car accident resulting in a first party payment, and/or an accident resulting in a citation.
10.  How many antique, classic and/or collectible vehicles are owned by you or any member of your household? Include private passenger vehicles licensed for road use, more than 20 years old, driven not more than 2,500 miles annually, owned for limited pleasure use, car shows and club events that are covered under a collector automobile policy. A $25 charge per antique/classic/collector vehicle applies.
11.  Have you or any other driver been licensed to drive in the U.S. less than one year, currently have a learner’s permit, and/or have a non-U.S. driver’s license?
12.  Have you or any other driver had an arrest, citation or conviction for driving under the influence of alcohol or drugs, reckless driving, careless driving (in Florida, careless driving with 4 or more points)?
13.  Has any one driver had more than 3 moving violations in the last 3 years?
14.  Has any driver under the age of 22 or over the age of 79 had a driving incident within the last 3 years? Incident means an at fault accident or moving violation.
15.  Do you or any member of your household own or lease timberland, or land which is farmed, in excess of 640 acres, for which the liability coverage is provided by either a Homeowners, Farmowners, or Farm Comprehensive Personal Liability Policy (including partial ownership)?
16.  Do you or any member of your household have an occupation of a professional entertainer or athlete, media personality, or an appointed or elected federal or state political figure?
17.  Have you or any member of your household had any personal liability or personal auto bodily injury liability claims for which payment by your insurance company exceeded $25,000 in the last 5 years?
18.  Are any of the residential properties owned or rented by you or any member of your household located outside the United States of America (including its territories and possessions), Puerto Rico or Canada?
19.  Does any other member of your household or other person residing in your household have a Personal Umbrella policy with RLI Insurance Company other than this policy?
20.  Do you or any member of your household own (including partial ownership) more than 5 residential properties rented to others that are not occupied in whole or in part at any time by you or any member of your household? Only 1-4 family units are eligible. Do not include residential properties covered under a commercial general liability policy as they are excluded from coverage.

Driver Information
Driver 1 Driver 2 Driver 3
Name:
Driver License No.:
Driver License State:
DOB:
Relationship to Applicant:

Additional Information
In the box below, please provide  any additional information  you feel may be necessary  for us to provide you with the best quote possible such as additional operators, coverages engines, etc.
 

Enter text above EXACTLY as it appears: