Umbrella Information: |
Full Name:
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Physical Address (P.O. Boxes Not Accepted):
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City:
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State:
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Zip Code:
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Phone Number:
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Email Address:
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Social Security Number (Your Privacy is Protected):
[to get you the best rate] |
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Driver's License Number (Your Privacy is Protected):
[to get you the best rate] |
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Date of Birth:
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Gender:
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Marital Status:
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Highest Completed Education:
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Occupation:
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Umbrella Insurance Coverage Amount Requested:
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1. How many motorized vehicles are licensed for road use (i.e., cars, motorcycles, motor homes, etc.) are owned, leased, rented, or regularly operated by you or
any member of your household? (Do not count antique, classic or collectible
vehicles. See question 10.):
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2a. How many residential properties are owned by you or any member of your
household? 1-4 family units are eligible and should be counted as one property. (Do
not include residential properties that are covered under a Commercial General
Liability Policy or other non-personal Premises Liability Policy since they are
excluded from coverage.):
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2b. How many residential properties are rented by you or any member of your
household? 1-4 family units are eligible and should be counted as one property. (Do
not include residential properties that are covered under a Commercial General
Liability Policy or other non-personal Premises Liability Policy since they are
excluded from coverage.):
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3. How many watercraft, between 14 and 45 ft. and with a maximum speed of 50 mph,
are owned or regularly operated by you or any member of your household?
Watercraft exceeding these limitations are excluded from coverage. (Do not count
canoes, jet skis, waverunners or other personal watercraft. See question 4.)
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4. How many jet skis, waverunners or other personal watercraft are owned or regularly operated by you or any member of your household?
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5. What is the total number of drivers? (Include drivers with a learner's permit.)
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6. How many drivers are under the age of 22? (Include any member of your household with a learner's permit or driver's license and see the definition of "driver" on
page 5.)
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7. How many drivers are age 70 or over? Note: This response is not considered when
determining the rating tier for applicants in Maine. (Include any member of your
household with a driver's license).
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8. How many moving violations have all drivers had within the last 3 years? (Include
DWI/DUI incidents within the last 5 years or 3 years in MT.) (See question 28).
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9. How many at-fault accidents have all drivers in your household had in the last 3
years? (See question 28).
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10. How many antique, classic and/or collectible vehicles are owned by you or any member of your household? (Max. of 25)
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11. How many residential properties owned or rented by you or any member of your household are located outside of the U.S. (including
its territories and possessions), Puerto Rico or Canada? (Max. of 5)
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12. How many acres of timberland and/or land that is farmed, for which the liability coverage is provided by a Homeowners, Farmowners or
Farm Comprehensive Personal Liability Policy do you or any member of your household own or lease (including partial ownership)?
(Max. of 1280)
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13. How many drivers have been licensed to drive in the U.S. less than one year, currently have a learner's permit, and/or have a non-U.S.
driver's license? A year or more with a learner's permit does not qualify as a year with a driver's license. (Max. of 8)
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14. How many driving incidents have all drivers ages 20-21 and/or age 80 or over had within the last 3 years? (Max. 1 per driver)
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15. How many arrests, citations or license suspensions for driving under the influence of alcohol/drugs, driving while intoxicated and/or any
other alcohol/drug related incidents have all drivers had in the last 5 years or 3 years in MT? (Max. 1 per household for drivers between
ages 22 and 79; 0 per household for drivers under ages 22 and 80 or over.)
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16. Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving (with 4 points in
FL), negligent driving and/or had a driver's license suspended (for reasons other than driving under the influence of alcohol
or drugs), revoked or refused in the last 5 years or 3 years in MT? (Careless or negligent driving N/A in SC)
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17. Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years?
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18. Do you or any member of your household have an occupation of a professional entertainer or athlete, media personality,
or an appointed or elected federal or state political figure? (N/A for political figures in FL, OR and TX.)
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19. Have you or any member of your household had any personal liability or personal auto bodily injury liability claims for
which payment by your insurance company exceeded $25,000 in the last 5 years?
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20. Does any other member of your household or other person residing in your household have a Personal Umbrella policy
with RLI Insurance Company?
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21. Do you or any member of your household own (including partial ownership) 6 or more residential properties rented to
others that are not occupied in whole or in part at any time by you or any member of your household? 1-4 family units are
eligible and should be counted as one property.
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22. Has any one driver had more than 3 moving violations in the last 3 years? (Include DWI/DUI incidents within the last 5 years or 3 years in MT.)
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23. Has any driver under the age of 20 had a driving incident within the last 3 years?
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24. Has any one driver ages 20-21 or age 80 or over had more than one driving incident within the past 3 years?
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25. Do you elect to purchase or reject Excess UM/UIM (Uninsured/Underinsured) coverage? (see below - write "purchase" or "reject" in the box) (Residents of FL, IN, LA, NH, VT, WI and WV: Submission of a state mandated form supersedes any response you
may make to this Question 25.) [Write "purchase" or "reject" below]
EXCESS UNINSURED/UNDERINSURED MOTORIST (UM/UIM) COVERAGE: Excess UM/UIM (Uninsured/Underinsured) coverage is offered for an
additional premium. Required Basic UM/UIM policy limits must be equal to the liability limits for the Required Basic Automobile Liability Policy. For residents of FL, IN, LA, NH, VT, WI or WV you must submit the referenced state mandated form.
FL and WV: If you elect to purchase this coverage, you are required to accept this coverage in writing and pay the additional premium. If you
accept UM/UIM coverage you must complete and return form PUP257B in FL or forms PUP547A and PUP547B in WV.
VT: Matching limits of UM/UIM are available for an additional premium. If you elect to reduce the UM/UIM limits to the statutory minimum of
$100,000, you must complete and return form PUP257D. Receipt of the applicable form by the company will result in a reduction in the premium.
WI: Limits of $100,000/$300,000 of UM, UIM or both UM/UIM are available for an additional premium. If you reject UM, UIM or UM/UIM
coverage, you must complete and return form PUP248A. Receipt of the applicable form by the company will result in a reduction in the premium.
IN, LA and NH: If you elect to reject UM/UIM coverage you must complete and return form PUP257A in IN and NH and PUP517 in LA. Receipt
of the applicable form by the company will result in a reduction in the premium.
All Other States: Excess UM/UIM coverage is offered at a limit of $1 million and an additional premium must be paid. For residents of all other
states you MUST write your answer below - "purchase" or "reject".
[Write "purchase" or "reject"] |
26. Do you and ALL members of your household agree to maintain the MINIMUM REQUIRED LIMITS OF LIABILITY coverage
outlined below as a condition of coverage? For those limits that currently do not apply to you or any member of your household, you must agree to maintain those limits only if they become applicable to you or any member of your household during the policy
period as a condition of your coverage. [Write "agree" or "disagree" below]
[+] PRIMARY RESIDENCE ONLY - REQUIRES
HOMEOWNERS OR COMPREHENSIVE
PERSONAL LIABILITY of
$300,000 per occurrence.
[+] SEASONAL, SECONDARY OR RENTAL
PROPERTIES - REQUIRE PREMISES
LIABILITY OR COMPREHENSIVE
PERSONAL LIABILITY of
$300,000 per occurrence.
NOTE: Residential properties that are
covered under a commercial or other
non-personal premises liability policy
are excluded from coverage.
[+] FARMOWNERS OR FARM - REQUIRES COMPREHENSIVE PERSONAL LIABILITY of
$300,000 per occurrence. (Required only if you or any member of your
household own a farm which is not covered
by your homeowners policy.)
[+] UNLICENSED RECREATIONAL VEHICLES (Including snowmobiles, ATVs, golf carts, etc.) - REQUIRES $100,000 Combined Single Limit per occurrence.
($325,000 in Texas)
-OR-
$100,000/$300,000/$25,000. (Required only if you or a member of your
household own or acquire an unlicensed recreational
vehicle during the policy period that is not
covered by your homeowners or personal liability
policy for the following limits of liability.)
[+] WATERCRAFT (Including boats, personal watercraft,
jet skis and canoes)
- REQUIRES $300,000 Combined Single Limits
-OR-
$250,000/$500,000/$100,000
-OR-
$300,000/$300,000/$100,000. (Required only if you or a member of your
household own or acquire a watercraft during the
policy period that is not covered by your
homeowners or personal liability policy for the
following limits of liability.)
NOTE: The RLI Personal Umbrella does not
provide coverage for watercraft exceeding
45 ft and/or 50 mph. This exclusion does not
apply to personal watercraft.
[Write "agree" or "disagree"] |
27. Which of the following MINIMUM REQUIRED LIMITS OF AUTOMOBILE LIABILITY do you and all members of your
household agree to maintain as a condition of coverage for all licensed vehicles, that are owned, leased, rented, operated or
acquired during the policy period? [Choose "A", "B" or "C" below]
If you elect to purchase Excess Uninsured/Underinsured Motorist (UM/UIM) coverage, the Required Basic UM/UIM Policy Limits must be equal to the liability limits for the Required Basic Automobile Liability Policy.
You agree that this condition applies equally to personal use of a vehicle covered under a Commercial Automobile Liability Policy.
[+] A:
$500,000 Bodily Injury per person/
$500,000 Bodily Injury per occurrence/
$100,000 Property Damage per occurrence
-OR-
$500,000 Combined Single Limit per occurrence
NOTE:
Limit A is ALWAYS REQUIRED if there are drivers under the age of 22 in the household.
-OR If
the answer to question 15 is 1 or more.
-OR In
KS and MA, if there are drivers with six
years or less driving experience in the household.
[+] B*:
$250,000 Bodily Injury per person/
$500,000 Bodily Injury per occurrence/
$100,000 Property Damage per occurrence
-OR-
$300,000 Bodily Injury per person/
$300,000 Bodily Injury per occurrence/
$100,000 Property Damage per occurrence
-OR-
$300,000 Combined Single Limit per occurrence
($325,000 in Texas)
[+] C*:
$100,000 Bodily Injury per person/
$300,000 Bodily Injury per occurrence/
$100,000 Property Damage per occurrence
NOTE: The choice of Limit C results
in a higher premium.
Excess UM/UIM is not available
if you maintain Limit C.
*Limits B and C are available options ONLY if all drivers in the household are age 22 and over.
Limit C is NOT available if there are any drivers age 70 or over in the household; and/or if any
response makes the risk Standard II (N/A in HI); and/or if any response makes the risk PUP
Special.
[Write "A", "B" or "C"] |
28. Complete the following for all members of your household age 14 and older. Also include on this list any other person who
operates a vehicle owned, leased, rented or regularly operated by you or a member of your household at least 50% or more of that
vehicle's use.
Household Member #1 (Over 14):
[Name]
[Date of Birth]
[Licensed or Permited]
[Drivers License or
Permit Number]
[State]
[Relationship to Applicant]
[Number of Violations 3 yrs (Incl. DWI/DUI
5 yrs/3 yrs MT)]
[Number of At-Fault Accidents (3 yrs)]
[Any DWI/DUI]
Household Member #2 (Over 14):
[Name]
[Date of Birth]
[Licensed or Permited]
[Drivers License or
Permit Number]
[State]
[Relationship to Applicant]
[Number of Violations 3 yrs (Incl. DWI/DUI
5 yrs/3 yrs MT)]
[Number of At-Fault Accidents (3 yrs)]
[Any DWI/DUI]
Household Member #3 (Over 14):
[Name]
[Date of Birth]
[Licensed or Permited]
[Drivers License or
Permit Number]
[State]
[Relationship to Applicant]
[Number of Violations 3 yrs (Incl. DWI/DUI
5 yrs/3 yrs MT)]
[Number of At-Fault Accidents (3 yrs)]
[Any DWI/DUI]
Household Member #4 (Over 14):
[Name]
[Date of Birth]
[Licensed or Permited]
[Drivers License or
Permit Number]
[State]
[Relationship to Applicant]
[Number of Violations 3 yrs (Incl. DWI/DUI
5 yrs/3 yrs MT)]
[Number of At-Fault Accidents (3 yrs)]
[Any DWI/DUI]
Household Member #5 (Over 14):
[Name]
[Date of Birth]
[Licensed or Permited]
[Drivers License or
Permit Number]
[State]
[Relationship to Applicant]
[Number of Violations 3 yrs (Incl. DWI/DUI
5 yrs/3 yrs MT)]
[Number of At-Fault Accidents (3 yrs)]
[Any DWI/DUI] |
Additional Information: |
Additional Comments:
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