Personal Umbrella Product Information
USLI writes unsupported personal umbrella liability for the
broadest range of applicant types in the industry. We offer
coverage for preferred, standard and high risk households, as
well as high profile individuals and farm and ranch owners.
PREFERRED APPLICANTS:
Operators between 23 and 75 years old
Limited exposure units (home, autos, RVs and watercraft)
Driving discounts apply
Zero accidents/DUIs; no more than 2 convictions
Limits up to $10 million on any quote ($5 million - FL;
$1 million - AL, MS, NH and VT; CT and ME if rentals)
Admitted in 45 states
STANDARD APPLICANTS:
Unlimited number of autos, RVs and watercraft up to 75’
Up to fifteen 1-4 family residential locations
Operator ages can range from age 23 through age 89
Six convictions in a household (3 years)
Three fault accidents in a household (3 years)
Limits up to $5 million on any quote ($1 million - AL, MS, NH
and VT; CT and ME if rentals)
Admitted in 45 states
HIGH RISK APPLICANTS:
Operators of any age; no maximum
Ten convictions in a household (3 years)
Five fault accidents in a household (3 years)
Any DUI in 5 years (zero if under age 23 or over age 89)
Limits up to $5 million ($1 million - AL, MS, NH and VT; CT
and ME if rentals)
Now admitted in most states
Any major category conviction in a household (3 years)
FARM AND RANCH OWNERS:
Farm revenues up to $1 million
2000 acres
250 grazing animals
Underlying liability must be on a personal lines form
CELEBRITY APPLICANTS:
Designed for high profile individuals such as pro athletes,
entertainers, politicians, Fortune 500 CEOs, TV and radio
personalities and authors
Admitted for preferred or standard applicant types
This document does not amend, extend or alter the coverage afforded by the policy. For a complete understanding of any insurance you purchase, you must first read your policy,
declaration page and any endorsements and discuss them with your broker. A specimen policy is available from an agent of the company. Your actual policy conditions may be
amended by endorsement or affected by state laws. .
Umbrella Product Information 1/14
USLI.COM
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ATTACHMENT REQUIREMENTS:
$250,000/$500,000/$100,000 or $300,000 CSL for autos,
home, watercraft or RVs
$500,000/$500,000/$100,000 or $500,000 CSL for autos and
watercraft for any account defined to be at risk
$500,000/$500,000/$100,000 or $500,000 CSL for autos and
personal liability for any farm and ranch applicant
$500,000 C.S.L. or $500,000/$500,000/$100,000 for all
exposures - Celebrity Applicants
$1,000,000 for any watercraft 51’ - 75’ or for autos with any
operator age 90 or over
COVERAGE FEATURES:
Optional excess UM/UIM available up to $1,000,000, $25,000
included in base rates
Broad definition of bodily injury and personal injury
True umbrella with drop down coverage for non owned
watercraft up to 26’, non owned RVs and non owned autos
outside the US
Worldwide coverage
Zero deductible
No aggregate limits
Coverage for both pre and post judgement interest
ADDITIONAL USLI ADVANTAGES:
Personal umbrella can be written in the name of individuals,
trusts, LLCs, LLPs or the estate of, if primary residence is
included
Quote instantly via phone, live web chat or 24-7 online
Direct access to underwriters to get what you need
A++ rated carrier and a Berkshire Hathaway Company
Automatic renewals with no renewal applications required
Direct Bill at new business and renewal with multiple
installments, all with no fees or interest
Instant access for service, endorsement changes and help
Personal Umbrella for Standard Applicants
Our Personal Umbrella for Standard Applicants is
designed for individuals with acceptable, but not perfect
driving records, mid-sized watercraft, and/or multiple
home and automobile exposures. It is available for
individuals who do not have local or national name and
face recognition. This product is now available on an
admitted basis in most states.
PRODUCT FEATURES:
u True Umbrella coverage
u Limits available up to $10,000,000 for risks that qualify
u $25,000 of Excess Uninsured/Underinsured Motorists
coverage included in the basic premium. Additional excess
UM/UIM limits are available
u Personal Injury Protection automatically included when
provided by underlying coverage
u First dollar coverage for Non-owned Watercraft and
Recreational Vehicles
u A.M. Best rated A++ carrier
PRODUCT ELIGIBILITY:
u Coverage available for vehicles, motorcycles, jet skis and
recreational vehicles
u Underlying coverage on a Personal lines form except for
underlying Business Auto or Garage forms
u One at fault accident
u Up to four violations in the household
u Unlimited number of watercraft if less than 25 feet
u Up to one watercraft 26-50 feet
ADDITIONAL ADVANTAGES:
u Fast and easy access to quote this product on our website
u Quick turnaround time on submissions
u Superior Policy Issuance
This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy,
Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be
amended by Endorsement or affected by State Laws.
PUSA-NR (11/05)
USLI.COM
USLI.COM
888-523-5545
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Personal Umbrella Product
Claim Examples
EEaacchh ddaayy bbrriinnggss nneeww ppoossssiibbiilliittiieess ffoorr uunnffoorrttuunnaattee aacccciiddeennttss aanndd
lliiaabbiilliittyy ccllaaiimmss.. MMaannyy ppeeooppllee ddoonn''tt rreeccooggnniizzee tthheeiirr lloossss
eexxppoossuurreess,, wwhhiicchh ccaann uunnffoorrttuunnaatteellyy rreessuulltt iinn ccaattaassttrroopphhiicc lloossss
aanndd ssiiggnniiffiiccaanntt ffiinnaanncciiaall bbuurrddeenn.. TThhee ffoolllloowwiinngg ccllaaiimmss sscceennaarriiooss
aarree ffaaccttuuaall ccllaaiimmss tthhaatt ccaann bbee uusseedd aass aann eeffffeeccttiivvee mmaarrkkeettiinngg ttooooll
ttoo hhiigghhlliigghhtt tthhee rreeaall ppoossssiibbiilliittyy ooff lloossss.. YYoouurr rreettaaiill ccuussttoommeerrss
sshhoouulldd uussee tthhee ffoolllloowwiinngg sscceennaarriiooss ttoo rreemmiinndd tthheeiirr ccuussttoommeerr
pprroossppeeccttss tthhaatt ffaaiilluurree ttoo ppuurrcchhaassee PPeerrssoonnaall UUmmbbrreellllaa iinnssuurraannccee
ccoouulldd ccoosstt tthheeiirr ffaammiillyy aa ffoorrttuunnee!!
IInntteerrnneett BBllooggggeerr::
The insured’
s daughter hated math class as
well as the teacher. The daughter made several
“disparaging” and false remarks about her teacher online.
The teacher sued the parents for personal injury and
$750,000 was paid.
FFaauullttyy FFuurrnnaaccee::
The insured’s tenant claims she became ill
from carbon monoxide poisoning resulting from a faulty
furnace. The tenant claimed permanent brain damage and
demanded $750,000.
CCooaacchhiinngg CCiirrccuummssttaanncceess::
A teena
ger, who was destined for
greatness as a softball player, filed a $700,000 lawsuit
against her former coach, alleging his “incorrect” teaching
style ruined her chances for an athletic scholarship.
FFaalllliinngg CCoonnccrreettee::
A hillside on the insured’s property was
covered with concrete to prevent erosion. The concrete had
been installed before the insured purchased the property.
Approximately 5 feet of the concrete fell to the neighboring
property knocking the claimant’s home from its foundation.
The resulting claim was settled for $970,000.
PPaaiinnttbbaallll MMiissffoorrttuunnee::
The insured permitted several of her
children and their friends to play paintball in her large back
yard. The children were experienced and advised of all the
safety rules including the use of headgear at all times. A
participant removed her headgear as she was leaving the
field in order to better hear someone calling her name. The
minor claimant was hit in the eye resulting in a $475,000
settlement.
BBeeaacchh EExxpplloossiioonn::
The insureds hosted a beach party for their
daughter. One of the attendees found what was believed to
be an empty and discarded propane tank. The tank was
thrown into a beach bonfire and subsequently exploded
resulting in severe injuries to several guests. A $20,000,000
claim was filed alleging the insured failed to properly
supervise the party.
This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy,
Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be
amended by Endorsement or affected by State Laws.
PU-CLA (9/06)
USLI.COM
USLI.COM
888-523-5545
888-523-5545
C
OVERAGE
F
EATURES
O
UR
G
ROUP
C
OMPETITORS
’
P
OLICY
Personal Injury coverage Provided if it is on underlying Umbrella
P
?
Coverage provided on a Following Form Basis
P
?
Worldwide Coverage, No limitation on where the suit is brought
against you
P
?
Limits of Liability up to $10,000,000
P
?
WHY CHOOSE TO BE INSURED WITH UNITED STATES LIABILITY INSURANCE GROUP?
u One of only 20 A++ rated insurance groups in the United States by A.M. Best.
u A proud member of the Berkshire Hathaway Group, recently voted the #1 most admired Property & Casualty Company in
the world (Fortune Magazine 2004).
Insure your financial well-being with a stable Company that will be there to pay your claim.
YOU HAVE WORKED HARD TO CREATE YOUR WEALTH, BUT ARE YOUR UMBRELLA LIMITS HIGH ENOUGH TO PROTECT IT WHEN
SOMEONE WANTS TO TAKE YOU TO COURT? YOU MAY BE TARGETED FOR A LAWSUIT BASED ON YOUR PERCEIVED NET WORTH.
u How much is enough liability insurance? If your liability coverage doesn't equal at least your net worth- the value of your home, cars,
retirement accounts and other possessions- you could lose it all!
u You can be held liable for what you say, write, or do to another person
u What if you hosted a party where alcohol is served? One of your guests leaves your party after having a few drinks and gets into an
automobile accident where they damage property and injured another driver on the road. You can be held liable
u What if you are involved in an accident, but you’re out of the country? Accidents happen everywhere not just at home. Your
exposures are the same while at home or away
ARE YOU PREPARED?
u Jury Verdicts continue to increase; they are up 240% since 1994 and this is in addition to Defense Costs
Not all Excess Personal Umbrella Policies are created equal. The following are important features; make sure you have them all:
Excess Personal Umbrella - Personal Lines
This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy,
Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be
amended by Endorsement or affected by State Laws.
XPL-POS-6-05
USLI.COM
USLI.COM
888-523-5545
888-523-5545
Excess Personal Umbrella Product - Personal Lines
This product is designed for those applicants who have a primary
personal umbrella policy with another company and desire higher
limits. Eligibility for this product is the same as our primary
personal umbrella.
PRODUCT FEATURES:
u Limits available up to $10,000,000; $5,000,000 in FL and
$1,000,000 in IN, VT, NH, MS & AL
u Available at a primary personal umbrella attachment point of
$1,000,000
PRODUCT ELIGIBILITY:
u No limit on the number of drivers, autos, recreational vehicles
and watercraft up to 75 feet
u Risks with multiple accidents and violations
u Households with up to 10 violations and five accidents
among all dri
vers
u Households with up to 10 violations and five accidents
among all dri
vers
u Indi
vidual drivers, over age 22, with one drug or alcohol
rela
ted offense
u Households with up to three major viola
tions, but not more
than tw
o per operator
u Co
verage available for farms with up to 2,000 acres, 250
g
razing liv
estock and revenues not exceeding $1,000,000
u Coverage available for high profile applicants
ADDITIONAL ADVANTAGES:
u Risks in the name of a trust, estate, LLC or LP are eligible
u A.M. Best rated A++ carrier
u Efficient online capabilities
u Motor vehicle reports ordered by the company
u Follow form umbrella coverage
This document does not amend, extend or alter the coverage afforded by the policy. For a complete understanding of any insurance you purchase, you must first read your policy,
declaration page and any endorsements and discuss them with your broker. A specimen policy is available from an agent of the company. Your actual policy conditions may be
amended by endorsement or affected by state laws.
EPL-NR (5/11)
USLI.COM
USLI.COM
888-523-5545
888-523-5545
Excess Personal Umbrella Product
Claim Examples
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uunnffoorreesseeeeaabbllee aacccciiddeennttss.. MMaannyy ppeeooppllee ddoonn’’tt rreeccooggnniizzee tthheeiirr lloossss
eexxppoossuurreess,, wwhhiicchh ccaann rreessuulltt iinn ccaattaassttrroopphhiicc lloossss aanndd ssiiggnniiffiiccaanntt
ffiinnaanncciiaall bbuurrddeenn.. TThhee ffoolllloowwiinngg ccllaaiimmss sscceennaarriiooss aarree ffaaccttuuaall
ccllaaiimmss tthhaatt ccaann bbee uusseedd aass aann eeffffeeccttiivvee mmaarrkkeettiinngg ttooooll ttoo hhiigghhlliigghhtt
tthhee rreeaall ppoossssiibbiilliittyy ooff lloossss.. YYoouurr rreettaaiill ccuussttoommeerrss sshhoouulldd uussee tthhee
ffoolllloowwiinngg sscceennaarriiooss ttoo rreemmiinndd tthheeiirr ccuussttoommeerr pprroossppeeccttss tthhaatt ffaaiilluurree
ttoo ppuurrcchhaassee EExxcceessss PPeerrssoonnaall UUmmbbrreellllaa iinnssuurraannccee ccoouulldd ccoosstt tthheeiirr
ffaammiillyy aa ffoorrttuunnee!!
IInntteerrnneett BBllooggggeerr::
The insured’ s daughter hated math c
lass as
well as the teacher. The daughter made several
“disparaging” and false remarks about her teacher online.
The teacher sued the parents for personal injury in the
amount of $1 million.
FFaauullttyy FFuurrnnaaccee::
The insured’s tenant claimed she became ill
from carbon monoxide poisoning resulting from a faulty
furnace. The tenant claimed permanent brain damage and
demanded $750,000.
CCooaacchhiinngg CCiirrccuummssttaanncceess::
A teenager, who w
as destined for
greatness as a softball player, filed a $700,000 lawsuit
against her former coach, alleging his “incorrect” teaching
style ruined her chances for an athletic scholarship.
FFaalllliinngg CCoonnccrreettee::
A hillside on the insured’s property was
covered with concrete to prevent erosion. The concrete had
been installed before the insured purchased the property.
Approximately 5 feet of the concrete fell to the neighboring
property knocking the claimant’s home from its foundation.
The resulting claim was settled for $970,000.
PPaaiinnttbbaallll MMiissffoorrttuunnee::
The insured permitted several of her
children and their friends to play paintball in her large back
yard. The children were experienced and advised of all the
safety rules including the use of headgear at all times. A
participant removed her headgear as she was leaving the
field in order to better hear someone calling her name. The
minor claimant was hit in the eye resulting in a $475,000
settlement.
BBeeaacchh EExxpplloossiioonn::
The insureds hosted a beach party for their
daughter. One of the attendees found what was believed to
be an empty and discarded propane tank. The tank was
thrown into a beach bonfire and subsequently exploded
resulting in severe injuries to several guests. A $20,000,000
claim was filed alleging the insured failed to properly
supervise the party.
This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy,
Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be
amended by Endorsement or affected by State Laws.
EPU-CLA (10/06)
USLI.COM
USLI.COM
888-523-5545
888-523-5545
USLI.COM
888-523-5545
Personal Umbrella/Excess Personal Umbrella Application
YOU CAN OBTAIN A QUOTE BY PROVIDING THE INFORMATIONI IN THE INSTANT QUOTE SECTION, SUBJECT TO THE REMAINDER PROVIDED PRIORTOBINDING.
I. INSTANT QUOTE INFORMATION
Instant Quote is only available for accounts with no losses in the past three years. If there is loss history, please complete the entire application.
Applicant’s name:_____________________________________________Occupation_________________________
Applicant type:
Individual(s) Trust Limited liability company Limited liability partnership Limited partnership Estate
NOTE: any type other than individual(s) requires submitting a completed Trust LLC Supplemental Questionnaire
E-mail address of applicant or applicant primary contact:__________________________________________________________________
Address of primary residence:______________________________________________________
Same as mailing address
City:______________________________________________________State:_______________________Zip:_______________________
Primary Personal Umbrella
Underlying personal liability limit:__________________________________________
Underlying auto bodily injury liability limit:____________________________________
Underlying U.M./U.I.M. limit:________________________________________________
Excess Personal Umbrella. If so, underlying primary umbrella limit: ________________
Does the applicant or any resident of the applicant’s household currently or have they at any time had
an occupation as an elected or appointed federal or state political figure, a professional athlete or coach,
entertainer, media personality or a senior executive or officer of a publicly traded company?
Yes No
Does the applicant own or lease any location used for Farm or Ranch operations?
Yes No
NOTE: Any “Yes” response requires submitting a completed Supplemental Farm Application
In addition to the primary residence:
Enter the number of owner occupied secondary residences ___________
Enter the number of 1-4 family residential units rented to others (Duplex = 2 units) ___________
How many Automobiles or Motor Homes are owned or furnished for the regular use of all operators in the household? ___________
How many Motorcycles, scooters, or other vehicles with less than four wheels and licensed for road use are owned
or furnished for the regular use of all operators in the household? ___________
How many recreational vehicles (vehicles not licensed for road use) are there in the household? ___________
Any watercraft? If "Yes," please complete watercraft information section
Yes No
Watercraft Information
Please list all watercraft owned, leased, chartered, or furnished for regular use
*1.Sailboat 2. Powerboat 3. Jet Ski / Wave Runner
**1. Inland U.S. 2. Coastal U.S. 3. International Waters
Year Description
(Make and Model)
Length *Type Max
Speed
Total
HP
**Waters Navigated Any Paid
Crew or
Captain
Underlying
Liability
Operator Information (Automobiles, Watercraft, Recreational Vehicles)
Please list all members of the applicants household age 14 or older, and all operators of Automobiles, Motorcycles, Watercraft
and Recreational Vehicles. NOTE: Please include those household members that are not yet licensed.
Driver Name Date of
Birth
License
Number
License State Moving
Violation
Convictions
(Last 3 Years)
*Major Moving
Violation
Convictions
(Last 3 years)
At Fault
Accidents
(Last 3 years)
Drug Alcohol
Related
Offenses
(Last 5 Years)
*Major moving violation convictions include, but are not limited to, speeding 25 or more over the posted limit, evading the Police,
leaving the scene, vehicular homicide, driving under a suspended license and reckless driving.
Personal Umbrella-APP 12/12- USLI
page 1 of 4
II.ELIGIBILITY QUESTIONS NOTE:
For any “Yes” response, please provide complete information in remarks area
1. Does the applicant or any member of the applicant’s household currently have any active policies
with the United States Liability Insurance Company, Mount Vernon Fire Insurance Company
or U.S. Underwriters Insurance Company?
Yes No
2. Has the applicant or any resident of the applicant’s household been convicted of or plead guilty to
a felony in the past fi ve years?
Yes No
3. Has the applicant or any resident of the applicant’s household had a liability loss greater than $50,000
in the past fi ve years or is there an open liability claim or lawsuit pending against them?
Yes No
4. Are any locations used as rooming houses, student housing other than a college dormitory room, assisted
living facilities or group home facilities?
Yes No
5. Are any locations to be included subsidized housing? (subsidized housing question N.A. in the states
of CA, CT, DC, ME, MA, NJ, OR, UT, VT, WI)
Yes No
6. Is there a pool at any location that is either unfenced or has a diving board or waterslide?
Yes No
7. Does the applicant or any resident of the applicant’s household operate any business or conduct any
professional activities that are covered by primary policies at any location to be covered?
Yes No
8. Are any locations leased to others for hunting, fi shing or other sporting or recreational purposes?
Yes No
9. Does the applicant or any resident of the applicant’s household own any exotic pets?
Yes No
10. Is there a dog exclusion on any primary homeowners or comprehensive personal liability policy?
Yes No
11. Is there an animal exclusion on any primary homeowners or comprehensive personal liability policy?
Yes No
12. Are the minimum underlying limits for automobiles covered completely by a business auto or garage policy?
Yes No
13. Is any of the required underlying Insurance provided by a commercial general liability policy or coverage form?
Yes No
14. Does any household operator have any restriction on his/her driver’s license other than glasses or
corrective lenses? NOTE: Any “Yes” response requires submitting a completed L252R Physicians Medical Statement.
Yes No
15. Do any of the Required Underlying Insurance Policies contain sublimits, have reduced limits of liability, or exclude
coverage for specifi c individuals or exposures?
Yes No
16. Is there currently, or during the next 12 months will there be, any construction, renovation or demolition at any
residential 1-4 family residence or condominium owned by or rented to the applicant?
Yes No
Residential Properties/Rental units and Apartments/Farms/Vacant Land. Include all units (duplex = 2 units)
Location Occupancy Underlying Liability Limit
Primary residence address
#units_____________________
Owner occupied
Tenant occupied #units____
Farm #acres____
Vacant land #acres____
Owner occupied
Tenant occupied #units____
Farm #acres____
Vacant land #acres____
* Any individual dwellings containing more than four units are ineligible
III.ADDITIONAL APPLICANT INFORMATION
Applicant’s mailing address (if different than primary residence address): ______________________________________________________
City:_______________________________________________________State: _____________________________Zip: _________________
Phone:________________________________________________________________________________________
Remarks
page 2 of 4
FRAUD STATEMENTS
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the
misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the
hazard assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an
amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as
required either by the application for the policy or otherwise.
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding
the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant.
Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Florida Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be
available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty
Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted market
and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect to any right of
recovery for the obligation of an insolvent unlicensed insurer.
Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida and Illinois
law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed punitive
damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy
provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited
to “vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.
Kansas Fraud Statement: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or
belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of,
an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit
pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any
fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto may be guilty of a crime and may be
subject to fines and confinement in prison.
Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime.
Maine Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. A binder may not be
withdrawn but a prospective notice of cancellation may be sent and coverage denied for fraud or material misrepresentation in obtaining
coverage. A policy may not be unilaterally rescinded or voided.
Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.Minnesota Notice:
Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information contained in this application
prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days
notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents,
occurrences or alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on the declarations. This
policy shall cover only those claims made against an insured while the policy remains in effect for incidents reported during the Policy Period or any
subsequent renewal of this Policy or any extended reporting period and all coverage under the policy ceases upon termination of the policy except for
the automatic extended reporting period coverage unless the insured purchases additional extend reporting period coverage. The policy includes an
automatic 60 day extended claims reporting period following the termination of this policy. The Insured may purchase for an additional premium an
additional extended reporting period of 12 months, 24 months or 36 months following the termination of this policy. Potential coverage gaps may arise
upon the expiration for this extended reporting period. During the first several years of a claims-made relationship, claims-made rates are comparatively
lower than occurrence rates. The insured can expect substantial annual premium increases independent overall rate increases until the claims-made
relationship has matured.
North Dakota Fraud Statement: Notice to North Dakota applicants – Any person who knowingly and with the intent to defraud and insurance company
or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil
penalty.
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement is guilty of insurance fraud.
Ohio Notice: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company are true and
correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage provided
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herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance applications are
incorporated into, and shall form part of, this policy. I understand that any material misrepresentation or omission made by me on this application may act
to render any contract of insurance null and without effect or provide the company the right to rescind it.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive Damages for
any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or exemplary
damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside the
state of Utah, for which coverage is sought under the same policy.
Vermont Fraud Statement: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance may be subject to fines and confinement in prison.
Virginia Notice: This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You have an option to
purchase a separate limit of liability for the extended reporting period. If you do not elect this option, the limit of liability for the extended reporting period
shall be part of the and not in addition to limit specified in the declarations. If you have any questions regarding the cost of an extended reporting period,
please contact your insurance company or your insurance agent. Statements in the application shall be deemed the insured’s representations. A statement
made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly
proven that such statement was material to the risk when assumed and was untrue.
Virginia Fraud Statement: Any person who knowingly and with intent to defraud an insurer, submits an Application for insurance or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
Utah Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement is guilty of insurance fraud.
Washington Fraud Statement: Any person, who, knowing it to be such:
(1) Presents, or causes to be presented, a false or fraudulent claim or any proof in support of such a claim, for the payment of a Loss under a contract of
insurance; or
(2) Prepares, makes, or subscribes any false or fraudulent account, certificate, affidavit, or proof of Loss, or other document or writing, with intent that it
be presented or used in support of such a claim, is guilty of a gross misdemeanor, or if such claim is in excess of one thousand five hundred dollars, of a
class C felony.
Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name: License#:
Agent’s signature: ____________________________________________________Main agency phone number _________________________________
(Required in New Hampshire)
Agency mailing address: ______________________________________________________________________________________________________
City: _____________________________________State: _____________________________ Zip: _________________________
The undersigned represents that to the best of his/her knowledge and belief the particulars and statements set forth herein are true and agrees that those
particulars and statements are material to acceptance of the risk assumed by the Company. The undersigned further declares that any changes to the
information contained in this application prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any
statement made will immediately be reported in writing to the Company and the Company may withdraw or modify any outstanding quotations and/or
authorization or agreement to bind the insurance. The Company is hereby authorized, but not required to make any investigation and inquiry in connection
with the information, statements and disclosures provided in this application. The decision of the Company not to make or to limit any investigation or
inquiry shall not be deemed a waiver of any rights by the Company and shall not stop the Company from relying on any statement in this application. The
signing of this application does not bind the undersigned to purchase the insurance, nor does the review of this application bind the Company to issue a
policy. It is understood the Company is relying on this application in the event the Policy is issued. It is agreed that this Application, including any material
submitted there with, shall be the basis of the contract should a policy be issued and it will be attached and become a part of the policy.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and
the stated value of the claim for each such violation.
Signature: __________________________________________________________________________________________________________________
(Chairperson of the Board, Managing Member, President or Executive Director)
Title: _______________________________________________________________ Date: _________________________________________________
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