Florida Alliance
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Florida Alliance



 
Personal Umbrella Insurance Quote

We would like to provide you with a free, no-obligation personal umbrella insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

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Personal Information
Name:
Address:
City:   State:   Zip:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM
Email Address:
EMPLOYMENT INFORMATION
Applicant's Occupation
Employer Name/Address
Yrs Empl.
Co-Applicant's Occupation
Co-Applicant's Employer Name/Address
Yrs Empl.

Umbrella Information
COVERAGES
Policy Amount
Retention
Optional Coverages to Apply
$
$
$
Uninsured Motorist
$
Underinsured Motorist
PREMIUMS
PLEASE NOTE:    In order to calculate total premiums below, please leave "0" amount
in any field below where you have no dollar amount to enter
Basic: $
Residences: $
Automobiles: $
Recreational Vehicles: $
Uninsured Motorist: $
Underinsured Motorist: $
Watercraft: $
$
$
TOTAL: $

Primary Policy Information
Type of Policy
Company/Policy Number
Policy Period
Limits of Liability
Single Limit
Bodily Injury
Property Damage
Automobile 
$
$
$
Personal 
Liability 
$
$
$
Watercraft 
$
$
$
Recreational 
Vehicles 
$
$
$
$
$
$
$
$
$

Real Estate
#
Name
Location
Description
Yr Built
Occupancy
(1)
(2)
(3)
(4)
(5)

Automobiles
Recreational Vehicles
List All Autos Owned, Leased,
or Furnished for Regular Use
List Motorcycles, Snowmobiles,
Dune Buggies, MiniBikes, Etc.
#
Year
Make and Model
#
Year
Type, Make and Model
(1)
(1)
(2)
(2)
(3)
(3)
(4)
(4)
(5)
(5)

Watercraft
List All Watercraft Owned, Leased, Chartered, or Furnished for Regular Use
#
Year
Type/Manufacturer/
Model
Length
Horse
Power
Max
Speed
Value
Waters
Navigated
(1)
 New
 Current
(2)
 New
 Current
(3)
 New
 Current

Operator Information
List all Household Members & All Operators of Vehicles/Watercraft
#
Name
DOB
Auto DL#/State Licensed
Vehicle, Craft, % Use, Etc.
(1)
(2)
(3)
(4)
(5)

Prior Experience/Losses
#
Please List Losses on Any Primary or Excess Policies
Exceeding $5,000 During the Last 5 Years
Carrier and Policy Number
(1)
(2)
(3)
(4)
(5)

General Information
  (1) Any Aircraft Owned, Leased, Chartered, or Furnished for Regular Use?
  Yes   No       If "Yes", please explain below:
 
  (2) Any Operators Convicted for any Traffic Violations During the Last 3 years?
  Yes   No       If "Yes", please explain below:
 
  (3) Any Operator Have Physical/Mental Imparement?  
  Yes   No       If "Yes", please explain below:
 
  (4) Any swimming pool on premises?
  Yes   No       If "Yes", please explain below:
 
  (5) Any Real Estate, Vehicles, Watercraft, Aircraft Used Commercially of for Business Purposes.?
  Yes   No       If "Yes", please explain below:
 
  (6) Any Real Estate, Vehicles, Watercraft, Aircraft, Owned, Hired, Leased, or Regularly Used, Not
        Covered by Primary Policies?
  Yes   No       If "Yes", please explain below:
 
  (7) Do You Engage In any Type of Farming Operation?
  Yes   No       If "Yes", please explain below:
 
  (8) Do You Hold any Non-Remunerative Positions?
  Yes   No       If "Yes", please explain below:
 
  (9) Any Full-Time Employees?   (Please Add Number of Employees)
  Yes   No       If "Yes", please explain below:
 
  (10) Any Non-Owned Property Exceeding $1,000 in Value, in Your Care, Custody, or Control?
  Yes   No       If "Yes", please explain below:
 
  (11) Any Business and/or Professional Activities Included in the Primary Policy?
  Yes   No       If "Yes", please explain below:
 
  (12) Does any Primary Policy Have Reduced Limits of Liability or Eliminate Coverage for Specific Exposures?
  Yes   No       If "Yes", please explain below:
 
  (13) Any Coverage Declined, Cancelled, or NonRenewed During the Last 5 Years?  
  Yes   No       If "Yes", please explain below:
 

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough fields above, please enter them here.

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