Umbrella / Excess Quote BUSINESS OWNERS PROGRAM Umbrella Quote Request 1) GENERAL INFO 1. Name of Business: 2. Mailing Address: 3. City, State, Zip CITY STATE ZIP 4. Contact Name: 5. Phone Number(s): DAYTIME FAX6. E-Mail Address: Desired Limits: (Each Occurrence / Policy Aggregate) (other limits may be available upon request) $1,000,000/$1,000,000 $2,000,000/$2,000,000 $3,000,000/$3,000,000 $4,000,000/$4,000,00Desired Self-Insured Retention: Select One None $10,000 Other if other, please Describe: Current Underlying Insurance Information Please complete teh table below with the information from your CURRENT underlying Automovile and Employers' Liability Policies. Employers’ Liability (Workers Compensation): CARRIER/POLICY # EFFECTIVE DATE EXPIRATION DATEAutomobile Liability CARRIER/POLICY # EFFECTIVE DATE EXPIRATION DATECSL $ BI $ PD $ Each Accident $ Disease Policy Limit Disease Each Employee $ Are the following published and distributed to all employees: a) Employee Manual? Select One Yes No b) Sexual Harassment Statement? Select One Yes No c) Equal Employment and Discrimination Statement? Select One Yes No d) Employee Grievance Procedures? Select One Yes No e) Discipline Procedures? Select One Yes No f) Is there an employment application used for all applicants? Select One Yes No g) Are annual written performance evaluations conducted for all employees? Select One Yes No Is the business self-insured for Workers’ Compensation or Employers’ Liability in any states? Select One Yes No Is the business subject to any of the following Workers’ Compensation laws? Jones Act FELA Stop Gap Federal Coal Mine Health and Safety Act US Longshoremen’s and Harbor Workers Compensation ActHas any product, work, accident, or location been excluded, uninsured or self-insured from any previous coverage? Select One Yes No If yes, provide details: Are any explosives, caustics, flammables or other dangerous cargo hauled? Select One Yes No Are any passengers transported for a fee? Select One Yes No Are there any autos that are not insured by an underlying policy? Select One Yes No Are any vehicles leased or rented to others? Select One Yes No Is Hired and Non-owned Auto coverage on an underlying auto policy? Select One Yes No Vehicles Used or Owned: Private Passenger: Any Property Hauled? Radius of Use: Select One 0-50 MI 50-200 MI Over 200 MI Trucks : Light 0 – 10,000 lbs. GVW Any Property Hauled? Radius of Use: Select One 0-50 MI 50-200 MI Over 200 MI Trucks Medium 10,001 – 20,000 lbs. GVW Any Property Hauled? Radius of Use: Select One 0-50 MI 50-200 MI Over 200 MI Does the business own or use any Buses, or Heavy or Extra Heavy Trucks and/or Tractors? Select One Yes No If yes, please describe the vehicles and what they are used for: Enter the code Powered by ChronoForms - ChronoEngine.com
