On-Line Umbrella
One Simple Form - takes only 2-3 Minutes!
Your Personal Data
Your Name:
Property Address:
City:
State: (Must be New Hampshire)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail Again (for accuracy):
Phone:
Fax (optional):
Umbrella coverage gives you a layer of liability coverage above your auto, homeowners, rental dwelling coverage, and RV
(cycle, motor home, etc.), up to the limit you select. Standard policy is a $1 Million
liability limit; but we also have policies available at $2 Million and $5 Million. Fill in ALL fields below:
Dwelling Information
# of dwellings you own and occupy (INCLUDING your home):
total UNIT count of all rental dwellings (NOT including units
you own and occupy):
Number of Automobiles you own (Describe Yr, Make & Model of each:
Number of RV's you own: (Include boats, RV's, motorcycles, motorhomes, etc.)
Vehicle Operator's Information
Number of Drivers:
List AGES of all drivers: (Include all children and household
members.)
Driving Records Clear? (If not, list all cites and accidents per
driver.)
Coverage Information
Limit of Coverage:
Underlying Auto Limits:
Underlying Homeowner Limits:
Underlying Rental Dwelling Limits: (Rentals must have $500,000 liability INCLUDING
Personal Injury coverages)
Currently Insured?
Name of Carrier & how long insured?
Prior Claims?
Describe claims in detail:
