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Umbrella


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Insured Information
Desired Effective Date *
/ /
First Name *
Last Name *
Named Insured (2)
Marital Status *
Location Address
ZIP / Postal Code *
Mailing Address
ZIP / Postal Code *
Contact Info.
Primary Phone Number *
E-Mail Address *
Current Insurance Information
Insurance Carrier *
Current Premium *
Policy No. *
Effective Dates *
Liability Limit *
Deductible *
# of Homes Owner Occupied *
# of Homes Rented to Others *
# of Familes of those Rented to Others *
# of vehicles *
# Owned or Leased *
# Furnished for Regular Use *
# of drivers *
# of Youthful Operators *
# of watercraft *
General
Are all underlying carriers rated B+ or better by A.M. Best? *
Has one or more of the risks been sued for libel, slander or discrimination? *
Has one or more of the risks had a liability claim(s) of $20k + in the past 5 yrs? *
Does one or more risk(s) handle, transport or store fireworks or ammunition? *
Automobile
Has one or more driver(s) had a license suspension, revocation or been refused a license for reasons related to the driving record of the driver in the last two (2) years? *
Has one or more driver(s) had a citation for driving under the influence of drugs or alcohol in the last two (2) years? *
Has one or more driver(s) had a citation for reckless driving, speed contest, vehicular manslaughter or homicide in the last two (2) years? *
Does one or more driver(s) own a high performance automobile and are under 30 years of age? *
Is one or more driver(s) involved in the organized racing or speed contest of any motor vehicle? *
Is one or more driver(s) covered in an assigned risk or similar plan or have restricted coverage under their primary insurance policy? *
Is one or more driver(s) under the age of 21 and have had an at-fault accident or two moving violations? *
Property
Does one or more insured(s) own a rental property larger than a four family dwelling? *
Does one or more insured(s) own more than four rental properties, including those that are four family dwellings? *
Does the risk(s) have an underground storage tank? *
Does the risk(s) have home daycare facilities on the residence premises? *
Are there animals of any type with a bite history on the premises? *
Watercraft
Is one or more driver(s) involved in the organized racing or speed contest of any motor vehicle? *
Does one or more insured(s) own any unusual watercraft including, but not limited to, a homemade boat, hydroplane, jet ski? *
Does one or more insured(s) own any watercraft that is more than 50 feet in length or has a total horsepower over 250? *
Pools/Tramplolines
Does the risk(s) have trampoline(s) including those with the safety nets? *
Does the risk(s) have a pool on the premises that is unfenced or has a sliding/diving board? *
Primary Policy Information
Type Of Policy *
Company Name/Policy Number *
Policy Period *
Limits of Liability: Single *
Limits of Liability: Bodily Injury *
Limits of Liability: Property Damage *
Real Estate
LIST ALL OWNED, LEASED OR OCCUPIED RESIDENCES, BUILDINGS, FARMS, VACANT LAND, ETC.
Location *
Description *
Year built *
Interest *
Occupancy *
Automobiles
LIST ALL AUTOS OWNED, LEASED OR FURNISHED FOR REGULAR USE
Year built *
Make and Model *
Recreational Vehicles
LIST MOTORCYCLES, SNOWMOBILES, DUNE BUGGIES, ETC.
Year built *
Make and Model *
Watercraft
LIST ALL WATERCRAFT OWNED, LEASED, CHARTERED OR FURNISHED FOR REGULAR USE
Motor Type, Make & Model *
Length, Horsepower & Max Speed *
Cost New & Current Value *
Waters Navigated *
Operator Information
LIST ALL MEMBERS OF THE HOUSEHOLD AND ALL OPERATORS OF VEHICLES/WATERCRAFT AS REQUIRED BY COMPANY
Name, Sex, Marital Status *
Date of Birth *
/ /
Date Licensed *
/ /
Drivers License # & Issuing State *
Vehicle/Craft
Percentage of Use *
Employment
Occupations Named Insured (1) *
Employer Name & Address *
Years Employed *
Occupations Named Insured (2)
Other Policy Endorsemens Not Described Above
Agency/Agent Information
Agency Number *
Agent Email Address *

IMPORTANT NOTICE

Please note that after your submission we will contact you with a price indication but it is ultimately up to the carrier to accept or reject each risk. All price indication are reliant upon the information you as the agent have provided to United Agency Alliance, L.L.C

 

Price indications will be subject to the carrier underwriting guidelines and final approval.  The carriers may obtain various underwriting reports which may include but not limited to C.L.U.E.,  credit and/or carrier specific reports. 

Any submissions made via this website do not constitute a binding agreement to a policy or coverages.  Changes to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  If you have any questions, please feel free to contact us.

Per the terms of our
online privacy policy we will not resell your information to any third-party.

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56 Payne Road
Lebanon, NJ 08833

P: 973.526.7038


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