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Vacant Dwelling

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

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
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