COMMERCIAL INSURANCE UNDERWRITERS, INC.
PERSONAL UMBRELLA APPLICATION
PH: 417.883.3277 / 800.241.9759 - Fax: 417.883.3393
Applicant's Name(s):
Agency Name:
Mailing Address:
Your Name:
City, State, Zip:
Email Address:
Inspection Contact Phone Number: Agency Address:
City, State, Zip:
Agency Phone Number:

REQUESTED EFFECTIVE DATE: TO            Renewal of Policy No.:

Requested Limit:

 

A.   Rating Information
   1.   a. List all owned, leased, or rented residential premises and any owned, leased, or rented farm, timber, or undeveloped land.
  Address No. of Families Farming? No. of Acres Pool? Fenced?  

1

 

2

 

3

 

4

 
        b. If Yes to Farming, type of Farming:
        c. If Yes to Farming, number of farm employees:

 

2.

List all licensed automobiles; i.e., private passenger, motor homes, pickups, motorcycles, ATVs, RVs, snowmobiles;

owned by, leased, furnished to, or available for your regular use including corporate owned vehicles.

  Year Make Model Type Company Car?
1
2
3
4

 

   3.   a. List all drivers including anyone who may be driving within the next year.  (MVRs required every three years.)
  Last Name First Name MI DOB Drivers License No. State Relationship Occupation
1
2
3
4
5

 

        b. Describe all violations, motor vehicle accidents or tickets for all operators during the past 36 months.
  Last Name First Name Date of Violation Description of Violation Amount Paid/Reserved  
1

 
2

 
3

 
4

 

 

        c. Have you or any driver in your household ever been cited, ticketed or convicted of driving under the influence of alcohol or drugs? 
            If Yes, please explain:

 

        d. Have you or any driver in your household ever had their driver's license suspended, revoked or refused? 
            If Yes, please explain:

 

        e. Have you or any driver in your household ever been cited, ticketed or convicted of reckless driving, hit and run or vehicular homicide?
            If Yes, please explain:

 

   4.  List all watercraft owned, rented or operated by members of your household. (Include any jet skis, Seadoos, etc.)
  Year Make Inboard, Inboard/Outboard or Outboard HP Maximum Speed (MPH) Length  
1  
2  
3  

 

   5.  ACCEPTANCE OR REJECTION OF UNINSURED/UNDERINSURED MOTORIST (MOTOR VEHICLE) COVERAGE APPLICATION ENDORSEMENT (Available only in Florida, Louisiana, New Hampshire, Ohio and Vermont):

I hereby reject the Uninsured/Underinsured Motorist (Motor Vehicle) coverage.  I understand that I am electing not to purchase a valuable coverage which would protect me or my family in the event of loss.

I desire coverage, at an additional charge, for $1,000,000 Uninsured/Underinsured Motorist (Motor Vehicle) coverage in my Personal Umbrella Liability insurance policy. I have purchased Uninsured/Underinsured Motorist (Motor Vehicle) coverage on all of my my motor vehicles for the full automobile insurance policy limits of my primary Automobile Liability insurance policy more fully described in my application for Personal Umbrella Liability insurance.

ADDITIONAL POLICY CONDITION:

In the event there is more than one insured listed on the Declarations page of a policy to which this endorsement is attached, acceptance or rejection by any one insured shall be deemed acceptance or rejection by all insureds.

_______________________________________________________________________ ______________
Signed                                                        (Insured) Date

 

B.  Underlying Information

   1. a. Do you hold any positions with non-profit organizations? 

       If Yes, please expain:
   b. Does your Personal Liability policy include Personal Injury coverage? 
   

   2. a. Do you or any member of your household own any animals or exotic pets? 

       If Yes, please explain:
   

   3. List the following required underlying policy information.  If any of this section is left blank we will not be able to consider your application.

  Automobile: Does your policy have limits of at least $250,000 each person, $500,000 or greater each accident for Bodily Injury and at least $100,000 for Property Damage or $500,000 or greater for a Combined Single Limit? 
  Do company provided vehicles have Drive Other Car coverage for all drivers? 
  Do you and all members of your household agree to maintain Uninsured and Underinsured Motorist limits equal to the Bodily Injury limit if coverage is elected (where applicable)? 

 

Insuring Company* Policy Number Limits of Liability as Shown on Your Policy

* (include company provided insurance and/or Drive Other Car coverage)

Homeowners', condominium owners', or tenants' insurance:

 

Does your underlying Personal Liability policy have limits of at least $300,000 and

Personal Injury liability of $300,000? 

 

Does your farm owners' and ranch owners' policy have limits of $500,000? 

 
Insuring Company Policy Number Limits of Liability as Shown on Your Policy
 

Underlying Watercraft Carrier, Limits and Policy:

Insuring Company Policy Number Limits of Liability as Shown on Your Policy
 

Personal Umbrella Policy:

Are we excess over this policy? 

Insuring Company Policy Number Limits of Liability as Shown on Your Policy

 

C.  General Information: (A Yes answer may affect your eligibility or premium.)

      1. Do you or any member of your household participate in organized racing of any motorized vehicles or

          watercraft? 

      2. Do you or any other member of your household have a Personal Umbrella policy with Scottsdale

          Insurance Company? 

      3. Have you or any member of your household had any Liability claims which exceed $5,000 in the last

          5 years? 

      4.a. Does any driver have any mental or physical condition that may affect their driving ability? 

 

  b. Explain any Yes answers:

       

APPLICANT STATEMENT

The information given on this application is true and complete to the best of my knowledge.  I understand that omission or misstatement of fact in the information given, which if known by Scottsdale Insurance Company would have caused Scottsdale Insurance Company to decline this application, is grounds for voiding this policy.  I further understand that minimum coverage limits on basic policies are necessary for full protection under the Personal Umbrella policy for which I am applying, and that no insurance will be in effect until the policy is issued.

 

PRIVACY POLICY:

 

I have received and read a copy of the "Scottsdale Insurance 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 Scottsdale Insurance 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.

 

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.

 

APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT'S AND PRODUCER'S SIGNATURES.

 

This application shall be the basis of the policy of insurance and deemed incorporated therein, should the Company evidence acceptance of the application by issuance of a policy.

 

APPLICANT'S SIGNATURE __________________________________________________ DATE ______________

 

PRODUCER'S SIGNATURE __________________________________________________ DATE ______________

 

AGENT NAME __________________________________________________   AGENT LICENSE NUMBER________________________

                                                                                         (Applicable to Florida Agents Only.)

 

IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: As a part of the underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living.  Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

 



Before You Submit your Application, Make Sure You Fill in the RED Boxes.  We Also Recommend Printing a Copy!!
TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
Select your account executive, if you have one. If you do not please select Marsha Peck: