Chan Insurance Agency, Inc.

Personal Umbrella Insurance Quote

Contact Information:

1. Full Name

2. Last Name

3. Phone

4. Evening Telephone:

5. Email:

6. Address:

7. City:

8. State:

9. Zip:

Underwriting Information:

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?

35. Comments or Questions:

36. Deliver quote via:

E-Mail
Fax
Regular Mail
Telephone

No coverage of any kind is bound or implied by submitting information via this online form
We value your privacy. Every precaution has been taken to insure your privacy and security. Our intent is to release information to you only. We will not provide your data to any third party or group for sales, marketing, or any other purposes. By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

By completing this form, you are acknowledging your understanding of and agreement with these terms

Umbrella Quote