Commercial Umbrella / Excess LiabilityQuote Request Please complete as much detail as possible. Fields marked with an asterisk (*) are required — our team is happy to help with the rest. 1 Insured Information Legal Business Name * DBA (If Applicable) Business Address * City * State * -- Select State --ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYDC Zip * Contact Name * Phone * Email * Website Years in Business Effective Date Requested * 2 Business Operations Describe your business operations * NAICS / Class Code (if known) States Where Operations Are Performed * 3 Coverage Request Type of Coverage * Umbrella LiabilityExcess Liability Limits Requested $1,000,000$2,000,000$3,000,000$5,000,000$10,000,000Other If "Other", specify requested limit Current Umbrella Carrier (if any) Current Limit Renewal Date 4 Business Information Annual Gross Sales Annual Payroll Number of Employees Number of Locations 5 Underlying Insurance Coverage Carrier Limits Expiration General Liability Commercial Auto Workers Compensation Employers Liability Professional Liability (if applicable) 6 Claims History Any liability claims in the past five (5) years? * NoYes Please provide details for each claim below. Claim 1 – Date Claim 1 – Description Claim 1 – Amount Paid/Reserved Claim 2 – Date Claim 2 – Description Claim 2 – Amount Paid/Reserved Claim 3 – Date Claim 3 – Description Claim 3 – Amount Paid/Reserved Additional claims (if more than 3) 7 Requested Covered Policies General LiabilityWorkers CompensationAuto LiabilityOther If "Other", please specify 8 Documents to Submit Attach what you have available now — you can always email the rest later. Accepted formats: PDF, DOC, DOCX (max 10MB each). Current General Liability Declarations Commercial Auto Declarations Workers Compensation Declarations Current Umbrella Declarations (if applicable) 3–5 Year Currently Valued Loss Runs
