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PERSONAL UMBRELLA INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a Personal Umbrella Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
Last
First
Middle
What is your business name?
Business Name
What is your address?
Street
City
State
Zip
What is your telephone number?
Home
Business
What is your fax number?
Fax
What is your email address?
Email
Underwriting Information
Are any aircraft owned, leased, chartered or furnished for regular use?
Aircraft
Yes No
Do any drivers have mental or physical impairments?
Mental or Physical Impairments
Yes No
Are any premises, vehicles, watercraft, aircraft used for business?
Used for Business
Yes No
Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies?
Not Covered by Primary Policies
Yes No
Do you engage ina any type of farming operation?
Farming Operations
Yes No
Do you hold any non-remunerative positions?
Non-Remunerative Positions
Yes No
Do you employ any residence employees?
Residence Employees
Yes No
Any non-owned property exceeding $1,000 in value in your care, custody or control?
Non-Owned Property Over $1,000
Yes No
Any non-owned business or professional activities included in the primary policies?
Non-Owned Business Activities
Yes No
Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?
Reduced Limits
Yes No
Was any coverage declined, cancelled or non-renewed within the past 5 years?
Coverage Declined
Yes No
Any motorcycles, mopeds or all terrain vehicles owned?
Motorcycles Mopeds or All Terrain Vehicles
Yes No
Any other business activities conducted from your residence or premises?
Other Business Activities
Yes No
Please explain any YES answers from above
Driver Information
Driver 1
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
Occupation
Driver 2
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
Occupation
Driver 3
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
Occupation
Driver 4
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
Occupation
Violation Information
Last 3 years (minor violations)
Last 5 years (major violations)
  Driver 1 Driver 2 Driver 3 Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless, hit and run, etc.
Miscellaneous and Claims Information
What is the number of single family dwellings you own?
Single Family Dwellings Owned
What is the number of autos you own?
Autos Owned
What is the number of recreational vehicles you own?
RV Owned
What is the number of multi-unit buildings you own?
Multi-Unit Buildings Owned
What is the number of vacant property (land) you own?
Vacant Property Owned
What is the number of motorcycles you own?
Motorcycles Owned
Where there any losses or claims in the last 5 years?
Losses - Claims
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?
Amount Current Coverage
What is the liability limit requested?
Liability Limit
Are there any questions, comments or additional coverage required?
Questions, Comments or Additional Coverage
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
Wm.Scott Carter Insurance Agency #0703360

1820 W Carson St. Ste 221 | Torrance, CA 90501
Phone 310-732-0023
Fax 866-234-0026
 
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