Home > Excess Liability Submission DatePolicy Holder NameBusiness Name*Website URLDetailed Description of Business OperationsPlease be very specific.PhoneEmail AddressAddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweState*ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZIP CodeBusiness Start DateType of Insurance neededProvide EIN Number if Workman's Compensation is needed.Projected Annual RevenueHave you had any Business Insurance Claims in the last 5 years?YesNoHow many full time employees?How many part time employees?Projected Annual PayrollYears of experienceDo you have a Security or Camera system?YesNoDo you have a Fire Alarm?YesNoDo you have a sprinkler systemYesNoWhat Industry do you work in?What is the estimated gross sales you will earn from your largest Client?Type of CompanyIndividual / Sole ProprietorCorporationLimited Liability CompanyLimited PartnershipNon-ProfitPartnershipTrustOtherWhat is the estimated gross sales you will earn from your largest Client?1. Do all primary carrier(s) have an AM Best rating of A-V or better?YesNo2. Are the applicant's General Liability and Auto Carriers (if applicable )liability limits $1million or greater?YesNo3. Does the applicant's underlying General Liability provide defense outside the limits of liability and uncapped?YesNo4. Has the applicant had any individual losses in excess of $25,000 in the past 5 years?YesNo5. Has the applicant incurred more than $100,000 in aggregate losses in any one year?YesNo6. Is the applicant involved in trucking?YesNo7. Does the applicant have annual receipts greater than $12.5 Million?YesNo8. Does the applicant have a formal safety program in place? Note: If yes, necessary documentation will be required such as a copy of the safety program.YesNo9. Does the underlying General Liability policy include a sunset clause?YesNo10. Is the Insured a General Contractor?YesNo11. Does the insured do any New Residential work?YesNo12. Does the insured do any grading, framing, foundation and excavation of new residential homes?YesNoExcess Coverage Limit$ 1,000,000$ 2,000,000$ 3,000,000$ 4,000,000$ 5,000,000$ 6,000,000$ 7,000,000$ 8,000,000$ 9,000,000$ 10,000,000Excess Coverage OverGeneral Liability OnlyGeneral Liability and AutoGeneral Liability and Worker's CompGeneral Liability, Worker's Comp, and AutoUnderlying GL Limits$300,000/$300,000/$300,000$500,000/$500,000/$500,000$500,000/$1,000,000/$1,000,000$1,000,000/$1,000,000/$1,000,000$1,000,000/$2,000,000/$2,000,000$1,000,000/$2,000,000/included$2,000,000/$4,000,000/$4,000,000Underlying GL PremiumDo you want Terrorism coverage?YesNoSend Message
