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Step One: Complete Form
Step Two: Review and Submit
Step Three: Finish
 
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[Form Version: 1.1]
[Updated: 06/16/08]
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Welcome to Commercial Umbrella Supplemental Application from A&M.

(Commercial Coverage for this program is only available when a personal umbrella policy is purchased)
For fast service on your umbrella accounts - complete the form below and hit the “Step Two” button.
Your submission will be electronically delivered to the next available Umbrella Underwriter.

Please note: In order to complete the application process, unless your client already has a personal umbrella with A&M, a Personal Umbrella Application must be completed.
 
Applicant Name
  Do not include individuals unless a sole proprietorship or partnership.
Mailing Adress
 
City State Zip Code
Applicant is:
Years in Business:
Section I
A. GENERAL LIABILITY - Questions 1 - 5 must be completed before submission.
1. Does the scheduled Primary policy(ies) include Personal injury?
2. Does the scheduled policy(ies) include Broad Form Property Damage for Distributing, Service, and Contracting risks?
3. Does the scheduled Primary policy(ies) include Contractual Liability?
4. Does the scheduled Primary policy(ies) include Products Liability?
5. Does the scheduled policy(ies) apply on an occurrence basis?
6. Name of Insurance Carrier(s) Limit of Liability Premium Minimum Limit Required
  $1,000,000 Each Occurrence
  $1,000,000 General Aggregate
  $1,000,000 Products & Completed Operations Aggregate
 
B. AUTOMOBILE LIABILITY
1. Do scheduled policies provide coverage for all owned and leased vehicles? (If no, coverage will be excluded)
2. Number of private passenger autos and light trucks (3/4 ton & less). #
3. Number of other trucks (i.e., over ¾ ton). #
4. Complete the following for each OWNED and / or LEASED business vehicle to be covered by this policy (if available, attach MVR):  
  Make / Model Principal Driver and Use*
1)
2)
3)
4)
5)
6)
 
* Use indicate if used for sales, delivery or primarily for personal transportation.  
5. List additional drivers not included above and indicate the make and model of vehicle driven.

 
6. Name of Insurance Carrier(s) Limit of Liability Premium Minimum Limit Required
 
 
C. NON-OWNED AND HIRED AUTOMOBILE
1. Is this coverage included in the scheduled underlying General Liability policy (if no, complete questions 2 and 3)?
2. Is this coverage included in your scheduled Automobile Liability Policy?
3. If this coverage is provided by a separate policy, please complete:  
4. Name of Insurance Carrier(s) Limit of Liability Premium Minimum Limit Required
 
 
D. EMPLOYERS LIABILITY
NONE AT INCEPTION
1. Name of Insurance Carrier(s) Limit of Liability Premium Minimum Limit Required
  $500,000 each accident
  $500,000 each employee for disease
  $500,000 policy limit
Section II - TYPE OF BUSINESS
CHECK ONE OR MORE BOXES AND COMPLETE THE REQUESTED INFORMATION.
STORES (provide the following for each location):
Number of Employees:
Location of store:
(Street address and city)
Annual gross receipts:
Total square feet:
Describe operations and what is sold:
OFFICE (provide the following for each location):
Number of Employees:
Location of office:
(Street address and city)
Annual gross receipts:
Total square feet: 
Describe operations:

VACANT LAND (provide the following for each location):
Location of office:
(Street address and city)
Total acreage:          OR  Total frontage feet:
LESSOR'S RISK (including apartments/condos) - provide the following for each building:
Location of property:
(Street address and city)
Number of stories:
Total square feet:
Construction:
Number of elevators:
Occupancy:
Year built:
If Apartment, # of units:
If Condo, # of units:
Public parking area square footage:
DISTRIBUTING, SERVICE OR CONTRACTING RISKS STORES
(provide the following for each code):
Number of Employees:
Annual M & C payroll:
Annual receipts:
Describe operations:
Cost and type of subcontracted work:
Section III - PLEASE COMPLETE FOR EVERY RISK SUBMITTED
1) Limit desired? Policy is not subject to a self insured retention: We offer up to $5M.
2) Upon acceptance of coverage by Anderson & Murison, the policy will be effective on the day following receipt of the premium payment by Anderson & Murison, unless a later date is requested. If later date, specify:
3) Expiration date should coincide with the underlying comprehensive general liability policy. If multiple policies, use the earliest date. Specify expiration date:
  EXPLAIN IN REMARKS SECTION IF YOUR ANSWER IS YES TO ANY OF THE FOLLOWING:
4) Has any claim of $10,000 or more (whether covered by insurance or not) been brought against the applicant within the last 5 years?
5) Do any underlying policies exclude coverage or reduce limits for any specific exposures which normally are fully covered (i.e., named driver exclusion, excluded operations, etc.)?
6) Is the applicant or any driver currently insured under an automobile assigned risk plan?
7) Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries not covered by this application?
8) Has any policy or coverage of the insured been declined, cancelled or nonrenewed within the past three years?
9) Does the applicant have any foreign operations or products?
    REMARKS
Producer Name
Contact Person
Phone Number  FAX Number:
Email Address  
 
    (You will get a summary page to review before submitting)