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Carrier – Personal Umbrella – Underwriting Questions
Matthias Allred
2025-01-22T17:07:00-07:00
PersonalUmbrella
Underwriting Questions
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Client Information
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UW Questions
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Questions
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Certification
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Google Drive
First Name
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Last Name
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Mobile Phone
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Email
The following questions apply to all household members.
1. Have you had any primary or excess insurance declined, canceled, or non-renewed in the past 5 years??
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No
Yes
1.5 Please describe
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2. Do you have any primary policies (home, auto, etc) which eliminate or restrict any coverage?
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No
Yes
2.5 Please describe
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3. Any accidents or traffic violations in 5 yrs (auto, RV or Watercraft)?
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No
Yes
3.5 Provide details
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4. Do you have any Physical, medical or mental/emotional impairments?
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No
Yes
4.5 Please provide details
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5. Are you providing Medical statement with the application?
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No
Yes
5.5 Upload Medical Statements
Max. file size: 10 MB.
6. Do you own, rent or operate any type of farm or farming operation?
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No
Yes
6.5 Please provide details
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7. Are you involved with unpaid civic duties, volunteer work or a non-profit corporations?
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No
Yes
7.5 Please provide details
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8. Do you travel to foreign countries more than 6 months per year?
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No
Yes
8.5 Please provide details
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9. Any liability claims or lawsuits against a household member in 5 yrs?
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No
Yes
9.5 Please provide details
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10. Do you own or lease any Real estate, vehicles, watercraft, aircraft that is not covered on a primary policy?
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No
Yes
10.5 Please provide details
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11. Aircraft owned, leased or charted for regular use?
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No
Yes
11.5 Please provide details
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12. Do you have any household employees/domestics?
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No
Yes
12.5 Please provide # of employees and indicate if they reside at the premise.
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13. Do you have a swimming pool at your house?
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No
Yes
13.5 Is the pool In ground or above ground?
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In Ground
Above Ground
Third Choice
13.6 Is the pool Fenced
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Yes, it is fully fenced
No it is not fenced
14. Do you have animals or exotic pets?
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No
Yes
15.5 Please provide details
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15. Are you a Professional Entertainer, Professional Athlete, Public Official, Famous Person?
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No
Yes
14.5 Please provide details
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16. Have you had four (4) or more losses or total losses over $25,000 within the past three years, or currently has an open claim.
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No
Yes
16.5 Please provide details
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Do you currently have an umbrella policy?
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Yes
No
Please provide the company name and amount of insurance.
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What is your Occupation?
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How many Personal Residences do you own/lease?
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Select One
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1
2
3
4
5
6+
How many Rental Properties do you own/lease?
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Select One
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1
2
3
4
5
6+
Do you own any Vacant Land?
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Select One
Yes
No
Provide Details on Vacant Land
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Include # Lots, #Acres, Rural or Urban areas.
How many Vehicles do you own/lease?
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Select One
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1
2
3
4
5
6+
How many Drivers are in the household?
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Select One
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1
2
3
4
5
6+
How many Drivers are under the age of 21?
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Select One
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1
2
3
4
5
6+
How many Drivers between age of 70-79?
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Select One
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1
2
3
4
5
6+
How many Drivers over the age of 79?
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Select One
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1
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5
6+
How many Drivers over the age of 89?
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Select One
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1
2
3
4
5
6+
How many Recreational Vehicles do you own/lease?
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Select One
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1
2
3
4
5
6+
How many Motorcycles do you own/lease?
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Select One
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1
2
3
4
5
6+
How many ATVs/UTVs do you own/lease?
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Select One
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1
2
3
4
5
6+
How many Boats/Watercrafts do you own/lease?
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Select One
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1
2
3
4
5
6+
How many Rental Properties do you own/lease?
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Select One
0
1
2
3
4
5
6+
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Form Category
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Form Name
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Agency Name
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AMS ID
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CRM ID
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Internal Use
Yes
Certification and Signature
I certify that I have answered the questions truthfully to the best of my knowledge
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Yes
Full Name
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By typing your full name, you are certifying that you have answered these questions truthfully to the best of your knowledge.
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