COMMERCIAL UMBRELLA APPLICATION
‰
Quotation
‰
New Business
Box 48 Cottonwood, Minnesota 56229
EFFECTIVE DATE: ______________________________
POLICY TERM: 1 YEAR
APPLICANT AND MAIL ADDRESS
AGENCY AND MAIL ADDRESS
AGT. NO._______
Phone No.:
Phone No.:
Fax No.:
UMBRELLA LIMIT (Non-binding): ‰ $1,000,000
‰ $2,000,000
‰ $3,000,000
‰ $4,000,000
‰ $5,000,000
DIRECT BILL INSTRUCTIONS:
‰ Insured
‰ Other__________________________
SELF-INSURED RETENTION: $10,000
New Business - 2 months premium required with application.
THE NAMED INSURED IS:
‰ Individual
‰ Corporation ‰ Partnership ‰ Other______________________________
A. LOCATION OF PREMISES:
Location
(Include 911 Address)
County
No. 1
No. 2
No. 3
B. DESCRIPTION OF OPERATIONS:
Location
On Premises
Off Premises
No. 1
No. 2
No. 3
C. ANNUAL PAYROLL: ______________________________________ D.
E.
NUMBER OF EMPLOYEES?_________ F.
ANNUAL SALES: _____________________________________
DO EMPLOYEES USE THEIR PERSONAL VEHICLES FOR BUSINESS? ‰ Yes ‰ No
G. AUTOMOBILES: Owned, leased or furnished for regular use
CHECK ONE
YEAR, MAKE AND MODEL
TYPE OF VEHICLE
OR
‰ Private Passenger
‰ 10,000 pounds or less
GROSS VEHICLE WEIGHT
‰ 10,001-20,000 pounds
‰ 20,001 and over
‰ Private Passenger
‰ 10,000 pounds or less
‰ 10,001-20,000 pounds
‰ 20,001 and over
‰ Private Passenger
‰ 10,000 pounds or less
‰ 10,001-20,000 pounds
‰ 20,001 and over
‰ Private Passenger
‰ 10,000 pounds or less
‰ 10,001-20,000 pounds
‰ 20,001 and over
CHECK ONE
RADIUS OF OPERATION
(Regular & Frequent Use)
‰ 1-50 Miles
‰ 51-200 Miles
‰ Over 200 Miles
‰ 1-50 Miles
‰ 51-200 Miles
‰ Over 200 Miles
‰ 1-50 Miles
‰ 51-200 Miles
‰ Over 200 Miles
‰ 1-50 Miles
‰ 51-200 Miles
‰ Over 200 Miles
NOTE: For additional vehicles, attach a separate memo with above information for each vehicle.
Any hauling for hire? ‰ Yes
‰ No If Yes, give details ______________________________________________________________________________________________
H. ALL LICENSED DRIVERS OPERATING BUSINESS VEHICLES:
Name
Drivers License Number
Date of Birth
No. 1
No. 2
No. 3
I.
J.
WATERCRAFT/REC. VEHICLE:
Describe owned or chartered watercraft/rec. vehicle and its use. ________________________________________________________
____________________________________________________________________________________ Does the underlying policy cover this exposure? ‰ Yes
‰ No
ADVERTISING LIABILITY: Describe all radio, television and publishing activities of the applicant planned for the next twelve months. _____________________________
_____________________________________________________________________________________________________________________________________________
Describe any other advertising activity planned for the next twelve months. (i.e., contests, exhibits, air shows, rodeos) ________________________________________________
_________________________________________________________________________________________________________________
REVERSE SIDE MUST BE COMPLETED
CF-425 (Ed. 11-09)
K. PRODUCTS:
L.
M.
N.
List products manufactured, sold, handled or distributed. __________________________________________________________________________________
_____________________________________________________________________________________________________________ Annual Sales $ __________________
COMPLETED OPERATIONS: Does applicant have a completed operations exposure? ‰ Yes
‰ No If Yes, explain _________________________________
__________________________________________________________________________________________________________ Annual Revenue $ __________________
CONTRACTUAL LIABILITY: Describe any contractual liability assumed by applicant other than liability assumed under any leases of premises, easement agreement,
agreement required by municipal ordinance, sidetract agreement, elevator or escalator maintenance agreement. ____________________________________________________
_____________________________________________________________________________________________________________________________________________
INDEPENDENT CONTRACTORS: Are Independent Contractors hired? ‰ Yes
‰ No If Yes, explain _____________________________________________
_____________________________________________________________________________________________________________________________________________
AIRCRAFT: Does applicant own, hire or use any aircraft? ‰ Yes
‰ No If Yes, explain ____________________________________________________________
O.
PRIMARY UNDERLYING INSURANCE: Minimum Required Limits
Commercial General Liability
Premises/Operations: $500,000 Each Occurrence and $1,000,000 General Aggregate
Commercial Automobile Liability, Including Non-Owned and Hired Car coverage
$500,000/$500,000 Bodily Injury
and
$100,000 Property Damage
Employers Liability:
or
Products/Completed Operations:
$1,000,000 General Aggregate
$500 Combined Single Limit
$100,000 Each Accident, $100,000 Each Employee Disease and $500,000 Policy Limit Disease
UNDERLYING INSURANCE: List all liability and compensation policies to apply as underlying insurance:
TYPE OF
INSURANCE
POLICY
NUMBER
INSURANCE
COMPANY
POLICY
Effective Date
Each Occur.
LIMITS
Products
POLICY
NUMBER
INSURANCE
COMPANY
POLICY
Effective Date
B.I.
LIMITS
P.D.
General Aggregate
COMM.
GENERAL
LIABILITY
CSL
COMM.
AUTO
LIABILITY
WORKERS COMP
(EMPLOYERS LIA)
Does the Primary Insurance cover the hazards listed below? (Indicating yes does not imply that the Umbrella provides coverage)
a. Products - Completed Operations
‰ Yes
‰ No
f. Garagekeepers Legal Liability
‰ Yes
‰ No
b. Blanket Contractual
‰ Yes
‰ No
g. Fire Legal Liability
‰ Yes
‰ No
c. Personal Injury
‰ Yes
‰ No
h. Commercial Auto Liability
‰ Yes
‰ No
d. Liquor Liability
‰ Yes
‰ No
i. Non-Owned Auto
‰ Yes
‰ No
e. x, c, u Exposures
‰ Yes
‰ No
j. Non-Owned Watercraft
‰ Yes
‰ No
Describe any extensions or limitations of coverage in the primary policies: ____________________________________________________________
_________________________________________________________________________________________________________________________________________________
LOSS EXPERIENCE: List all losses paid or now reserved in amounts greater than $10,000 during past five years.
(Show total amounts for each loss, not just amounts over $10,000.)
AMOUNTS OF LOSSES
DATE OF
ACCIDENT
PAID
DESCRIPTION OF ACCIDENT
B.I.
P.D.
OUTSTANDING
B.I.
P.D.
THIS IS NOT A BINDER OF COVERAGE
NOTICE - READ BEFORE SIGNING - As the applicant for this insurance, I grant permission to the agency listed on the front and to the underwriting department of North Star Mutual
to obtain claims information from previous insurer(s) and/or reports from investigative consumer organizations as to my credit (or credit-based insurance score), character, and/or condition
of the property represented on this application. I understand that I have the right to make a request in writing as to the nature of any such information that may be developed and that
I have the right to request that any such information be corrected by providing documented support for such correction. If my request is denied, I understand that I have the right to appeal
to the Commissioner/Director (Minnesota Commissioner of Commerce, 85 7th Place East, Suite 500, St. Paul, MN 55101-2198; Nebraska Director of Insurance, Terminal Building, 941
"O" Street, Suite 400, Lincoln, NE 68508-3639; North Dakota Commissioner of Insurance, 600 East Boulevard Avenue-5th Floor, Bismarck, ND 58505-0320; South Dakota Director
of Insurance, 445 East Capitol Ave, Pierre, SD 57501-3185; Iowa Commissioner of Insurance, 330 Maple St., Des Moines, IA 50319-0065). I understand that in MN only, this is a temporary
authorization that will expire as soon as one of the following occurs: (a) The above named company makes the underwriting decision(s) in question, or (b) one year elapses after the date
I sign this authorization. However, if a policy is issued, then I authorize the above permission for subsequent amendments and renewals as long as the policy remains in-force.
If this application for insurance is accepted, I grant permission to North Star Mutual to disclose information to the Mortgagee(s) or Loss Payee(s) that may be designated in this application
or its(their) successor(s). (Reports prepared by insurance-support organizations may be retained by them and disclosed to others.) INSURANCE FRAUD IS A CRIME - I understand
that a person who submits an application or claim information with intent to defraud an insurer is guilty of a crime.
Applicant's Signature ________________________________________________________________________________________________ Date ________________________
As the Agent for the applicant, I attest that the information in this application and attachments is correct to the best of my knowledge.
Agent's Signature ___________________________________________________________________________________________________
Date ________________________