10 |
Are any aircraft owned, leased, chartered
or furnished for regular use? |
Yes
No |
11 |
Do any drivers have mental or physical impairments? |
Yes
No |
12 |
Are any premises, vehicles, watercraft, aircraft used for business? |
Yes
No |
13 |
Are any premises, vehicles, watercraft, aircraft owned, hired,
leased or regularly used not covered by the primary policies? |
Yes
No |
14 |
Do you engage ina any type of farming operation? |
Yes
No |
15 |
Do you hold any non-remunerative positions? |
Yes
No |
16 |
Do you employ any residence employees? |
Yes
No |
17 |
Any non-owned property exceeding $1,000 in value in your care,
custody or control? |
Yes
No |
18 |
Any non-owned business or professional activities included in
the primary policies? |
Yes
No |
19 |
Does any primary policy have reduced limits of liability or eliminate
coverage for specific exposures? |
Yes
No |
20 |
Was any coverage declined, cancelled or non-renewed within the
past 5 years? |
Yes
No |
21 |
Any motorcycles, mopeds or all terrain vehicles owned? |
Yes
No |
22 |
Any other business activities conducted from your residence or
premises? |
Yes
No |
23 |
Please explain any YES answers from above |
|
24 |
Are there drivers under 25 yrs of age? |
|
25 |
If yes state how many: |
|
26 |
What is the number of autos you own? |
|
27 |
What is the number of recreational vehicles
you own? |
|
28 |
What is the number of single family
dwellings you own? |
|
29 |
What is the number of multi-unit buildings
you own? |
|
30 |
What is the number of vacant property
(land) you own? |
|
31 |
What is the number of motorcycles you
own? |
|
32 |
Where there any losses or claims in
the last 5 years? |
Yes
No |
33 |
If yes, what is the date, amount paid
and description of each loss or claim? |
|
34 |
What is the liability limit requested? |
|
|
Social Security #: |
|
