Umbrella Application

Broker Information
Are you a broker? (Y/N)    If so, please complete this section.
Company Name (Broker)
Name
Address
Address
City State Zip
Phone    Fax
E-Mail Address


Name and Address of Insured
Company Name (Insured)
(Required)
Name
(Required)
Address
Address
City State Zip
Phone    Fax
E-Mail Address
(Required)
Total Employees Annual Sales Year Established


Description of operations


Schedule of Underlying
CARRIER LIMITS EFF. DATE PREMIUM


Describe any losses over $25,000:



Requested Limit:  
Premium:  


The insured's receipts for the last three (3) years:
Year Receipts Growth Rate (%)


Automobile Fleet Breakout (including foreign vehicles):  
Private Passenger Vehicles
(Including Hired and Non-Owned)
Light Trucks
(Including 1-8 Passenger Vans)
Medium Trucks
(Including 9-20 Passenger Vans)
Heavy Trucks
(Units not for hire)
Extra Heavy Trucks/Tractors
(Short haul) (Units not for hire)
Extra Heavy Trucks/Tractors
(Long haul) (Units not for hire)
Buses
(Over 20 passengers only)
Does the automobile fleet contain any of the following exposures? (Y/N)
School Buses or Vans, Police Vehicle, Fire Trucks, Ambulances, Buses (in excess of 20 passenger), Rapid Delivery Operations (example, pizza, newspaper, magazine delivery), Gasoline Hauling, Hazardous Waste/Red Level or Commodity III or IV Hauling?
Are any vehicles registered or principally garaged in New York? (Y/N)


Habitional Risks  
Number of Units




Is this request being submitted by the insured or by the current insurance broker?    

     

By clicking "Submit Form", this form will be emailed to The Umbrella Factory. We will promptly process your request and contact you with further information. You are under no obligation to purchase any coverage until you accept our proposal.