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Group Excess (PL) - High Limit Request Form
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What is your first name?
What is your first name?
What is your last name?
What is your last name?
What is your email address?
What is your email address?
What is your employer's name?
What is your employer's name?
What is your home address?
What is your home address?
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
How many residences do you own/lease that are occupied by you?
How many residences do you own/lease that are occupied by you?
How many residences do you own/lease that are not occupied by you?
How many residences do you own/lease that are not occupied by you?
How many vehicles do you or another resident relative own or lease?
How many vehicles do you or another resident relative own or lease?
How many family members are licensed to drive?
How many family members are licensed to drive? (Include all dependents and family mmbers living in the residences you own or lease.)
How many licensed drivers are under 25 years of age?
How many licensed drivers are under 25 years of age?
How many recreational vehicles do you own? (non-licensed for road use.)
How many recreational vehicles do you own? (non-licensed for road use.)
How many watercraft do you own?
How many watercraft do you own?
How many watercraft are over 26 foot in length or over 50 engine rated horsepower?
How many watercraft are over 26 foot in length or over 50 engine rated horsepower?
Does your watercraft have a maximum speed greater than 45 mph?
Does your watercraft have a maximum speed greater than 45 mph?
Yes
No
Please enter the year, make, model and length of any watercraft that has a maximum speed that is over 45 mph.
Please enter the year, make, model and length of any watercraft that has a maximum speed that is over 45 mph.
Year
Make
Model
Length (Ft)
Please provide some details about the watercraft operator's experience.
Please provide some details about the watercraft operator's experience.
Are any of your watercraft greater than 50 feet in length?
Are any of your watercraft greater than 50 feet in length?
Yes
No
What is the total number of crew?
What is the total number of crew?
Please provide details regarding the experience of this vessel's operator.
Please provide details regarding the experience of this vessel's operator.
Have you or any of the licensed drivers in your household had any motor vehicle violations in the past three years?
Have you or any of the licensed drivers in your household had any motor vehicle violations in the past three years?
Yes
No
Please list all motor vehicle violations for all licensed drivers during the past three years:
Please list all motor vehicle violations for all licensed drivers during the past three years:
Driver Name
Violation Description
Have you had any liability claims under your homeowners, personal automobile, or watercraft policies in the past five years?
Have you had any liability claims under your homeowners, personal automobile, or watercraft policies in the past five years?
Yes
No
Please list all liability claims during the past five years that were submitted under your homeowners, personal automobile, or watercraft policies:
Please list all liability claims during the past five years that were submitted under your homeowners, personal automobile, or watercraft policies:
Policy Type (Home, Auto, Watercraft)
Claim Description
Please enter the below information for all drivers in the household:
Please enter the below information for all drivers in the household:
Driver Name (as it appears on license)
Date of Birth (MM/DD/YY)
License State
Drivers License Number
What is the name of your current home insurance company?
What is the name of your current home insurance company?
AIG Private Client Group
Berkley One
Chubb Personal Risk Services
Cincinnati Insurance Company
PURE Insurance
What is the name of your current automobile insurance company?
What is the name of your current automobile insurance company?
AIG Private Client Group
Berkley One
Chubb Personal Risk Services
Cincinnati Insurance Company
PURE Insurance
What is the name of your current watercraft insurance company?
What is the name of your current watercraft insurance company?
AIG Private Client Group
Berkley One
Chubb Personal Risk Services
Cincinnati Insurance Company
PURE Insurance
Cecilia Rivera
860-868-7361
http://ericsoninsurance.com/
Cecilia_Rivera@ajg.com
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