PERSONAL UMBRELLA APPLICATION - CCW Insurance

1 ACORD 83 (2012/02)PAYMENT PLAN (Attach ACORD 610, Premium Payment Supplement, if additional information is required)FINANCE COMPANYY/NPREMIUM FINANCED ?MORTGAGEEINSUREDPAYORPRE-AUTHORIZED DRAFT/CHECK (PAC)PAYROLL DEDUCTIONEFTCREDIT CARDCHECKCASHPAYMENT METHODMONTHLYBI-MONTHLYQUARTERLYSEMI-ANN UALANNUALFULL PAYPAYMENT PLANMAIL POLICY TO:AGENTINSUREDAGENCY BILLDIRECT BILL - ACCTDIRECT BILL - POLICYBILLINGBILLING ACCOUNT #:EST TOTAL PREMIUM:DEPOSIT AMOUNT:$$ date AT CURRENT RESIDENCE:PHONE #CELLHOMEBUSPRIMARYPHONE #SECONDARYCELLHOMEBUSSECONDARY E-MAIL ADDRESSPRIMARY E-MAIL ADDRESSPOLICY NUMBER:APPLICANT'S NAME AND MAILING ADDRESS (include county & ZIP+4)EFFECTIVE DATEEXPIRATION DATECARRIERNAIC CODEPLANFACILITY CODEFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAILor CSLEA ACCor CSLEA ACCor CSLEA ACCor CSLEA ACCor CSLEA ACCor CSLEA ACC$PROPERTY DAMAGEEFF:EXP:POLICY NUMBER:COMPANY.

2 EA PEREA PER$PD EA ACC$PD EA ACC$PD EA ACC$EFF:EFF:EFF:EFF:EFF:EXP:LIMIT$EMPLOY ERS LIABILITYEXP:$EA PER$EA ACC$$$UNINSURED MOTORISTSEXP:POLICY NUMBER:COMPANY:LIABILITYPROPERTY DAMAGE$EA PER$$$UNINSURED BOATERSLIABILITYEA OCC$ PERSONAL LIABILITYEXP:DWELLING FIREINCL RENTALSPOLICY NUMBER:COMPANY:EA OCC$ PERSONAL LIABILITY$EA PER$EA ACC$EXP:HOME$EA ACCEA PER$UNINSURED MOTORISTSEXP:EFF:COMPANY NAME / POLICY NUMBERPOLICY NUMBER:COMPANY:POLICY NUMBER:COMPANY:POLICY NUMBER:COMPANY:POLICY NUMBER:COMPANY:EMPLOYERS LIABILITYRECREATIONAL VEHICLESPRIMARY POLICY INFORMATIONTYPE OF POLICYPOLICY PERIODLIMITS OF LIABILITYLIABILITYPROPERTY DAMAGEAUTOWATERCRAFTDEPOSIT$LIMITCOVERAG E$$CODE$LIMITCOVERAGE$$$$$$$$$ESTIMATED TOTAL PREMIUMWATERCRAFTUNDERINSURED MOTORISTUNINSURED MOTORISTRECREATIONAL VEHICLESAUTOMOBILESRESIDENCESBASIC* IF APPLICABLE IN YOUR STATEUNDERINSURED MOTORIST *UNINSURED MOTORIST *$OPTIONAL COVERAGES TO APPLY$$RETENTIONPOLICY AMOUNTCALCULATIONSPREMIUMSCOVERAGESUMBRE LLA INFORMATIONDATE (MM/DD/YYYY) PERSONAL UMBRELLA APPLICATIONPage 1 of 6 The ACORD name and logo are registered marks of ACORD 1984-2012 ACORD CORPORATION.

3 All rights 83 (2012/02)* MAR* MARITAL STATUS / CIVIL UNION (if applicable)Page 2 of 6 STATLAST NAMEMIDDLE NAMEFIRST NAMENAME (AS IT APPEARS ON LICENSE) date OF BIRTH#SEXOTHER% USECRAFT% USEVEHICLESTATELICDATE LICDRIVERS LICENSE #SOCIAL SECURITY ##LIST ALL MEMBERS OF HOUSEHOLD AND ALL OPERATORS OF VEHICLES / WATERCRAFT AS REQUIRED BY COMPANYOPERATORS###GULF OF MEXICORIVERSPACIFICINLAND WATERWAYSGREAT LAKESATLANTICWATERS NAVIGATEDSAILOUTDRIVEWATERJETINBOARD /OUTBOARDINBOARDPOWERGULF OF MEXICORIVERSPACIFICINLAND WATERWAYSGREAT LAKESATLANTICWATERS NAVIGATEDSAILOUTDRIVEWATERJETINBOARD /OUTBOARDINBOARDPOWERGULF OF MEXICORIVERSPACIFICINLAND WATERWAYSGREAT LAKESATLANTICWATERS NAVIGATEDSAILOUTDRIVEWATERJETINBOARD /OUTBOARDINBOARDPOWERMODELSPEEDMAXPOWERH ORSELENGTHMANUFACTURERYEAR#LIST ALL WATERCRAFT OWNED, LEASED, CHARTERED OR FURNISHED FOR REGULAR USEWATERCRAFTBODY TYPEMODELAUTOMOBILES AND RECREATIONAL VEHICLESLIST ALL AUTOS OWNED.

4 LEASED OR FURNISHED FOR REGULAR USE AND MOTORCYCLES, SNOWMOBILES, DUNE BUGGIES, MINIBIKES, etc.#YEARMAKENO PRIOR COVERAGEPRIOR POLICY NUMBERPRIOR CARRIERPRIOR COVERAGEEXPIRATION DATEAGENCY CUSTOMER ID:PROPERTYLIST ALL OWNED, LEASED OR OCCUPIED PROPERTY, INCLUDING RESIDENCES, BUILDINGS, FARMS, VACANT LAND, etc.#LOCATION INFORMATIONDESCRIPTIONYR BUILTINTERESTOCCUPANCYUSAGEACORD 83 (2012/02) (Y / N)SAFETY NET (Y / N)LOC #SAFETY NET (Y / N)LOC #SAFETY NET (Y / N)LOC #SAFETY NET (Y / N)LOC #OUTSIDEINSIDEOUTSIDEINSIDEDUTIESHRS /WEEKPART TIME# EMPLOYEES$LOC #Check all that apply:OTHERSLIDEBOARDDIVINGFENCEAPPROVED GROUNDINGROUNDDESCRIPTIONLOC #OUTSIDEINSIDEOUTSIDEINSIDE$DUTIESHRS /WEEKFULL TIME# EMPLOYEESTOTAL PAYROLL ALL EMPLOYEESBITE HISTORYBREEDANIMAL TYPEABOVEY / NGENERAL INFORMATIONEXPLAIN ALL "YES" RESPONSESANY AIRCRAFT OWNED, LEASED, CHARTERED OR FURNISHED FOR REGULAR USE?

5 SWIMMING POOL, SPA OR HOT TUB ON PREMISES? REAL ESTATE, VEHICLES, WATERCRAFT, AIRCRAFT USED COMMERCIALLY OR FOR BUSINESS PURPOSES? REAL ESTATE, VEHICLES, WATERCRAFT, AIRCRAFT, OWNED, HIRED, LEASED OR REGULARLY USED, NOT COVERED BY PRIMARY POLICIES? EMPLOYEES? APPLICANT OR ANY TENANT HAVE ANY ANIMALS OR EXOTIC PETS?IS THERE A TRAMPOLINE ON THE PREMISES? EMPLCO-APPLICANT'S EMPLOYER NAME AND ADDRESSCO-APPLICANT'S OCCUPATIONYRS EMPLAPPLICANT'S EMPLOYER NAME AND ADDRESSAPPLICANT'S OCCUPATIONEMPLOYMENT(Three [3] years in KS)2. A speeding violation of up to ten (10) mph that occurs in an area with a maximum posted speed limit from 55 mph through 75 A speeding violation of up to six (6) mph that occurs in an area with a maximum posted speed limit from 30 mph through 54 mph, orIMPORTANT: UNDER KANSAS LAW, THE FOLLOWING TRAFFIC VIOLATIONS ARE NOT REQUIRED TO BE REPORTED TO INSURERS:EXPLANATIONDRV #ANY DRIVER UNDERGOING A COURSE OF MEDICAL TREATMENT FOR A PHYSICAL / MENTAL IMPAIRMENT?

6 (Not applicable in OR and WI) OF SPECIAL EQUIPMENT IN VEHICLEDRV #ANY DRIVER HAVE A PHYSICAL IMPAIRMENT? (Not applicable in OR and WI) $$$DATEDESCRIPTIONDRV #$COSTDRV #DESCRIPTIONY / NEXPLAIN ALL "YES" ANY AUTO ACCIDENT OR LIABILITY LOSS ON ANY PRIMARY OR EXCESS POLICY OCCURRED, REGARDLESS OF FAULT DURING THE OPERATORS CONVICTED FOR ANY TRAFFIC VIOLATIONS DURING THE LAST THREE (3) YEARS?OPERATOR INFORMATIONPage 3 of 6 AGENCY CUSTOMER ID:ACORD 83 (2012/02)DO YOU ENGAGE IN ANY TYPE OF FARMING OPERATION? / NEXPLAIN ALL "YES" RESPONSESGENERAL INFORMATION (continued)HAS Insurance BEEN TRANSFERRED WITHIN THE AGENCY?15. REASON DECLINED, CANCELLED, OR NON-RENEWEDDRV #ANY COVERAGE DECLINED, CANCELLED, OR NON-RENEWED DURING THE LAST FIVE (5) YEARS? (Missouri Applicants - Do not answer this question)14.

7 YOU HOLD ANY NON-COMPENSATED POSITIONS? NON-OWNED PROPERTY EXCEEDING $1,000 IN VALUE, IN YOUR CARE, CUSTODY OR CONTROL? BUSINESS AND/OR PROFESSIONAL ACTIVITIES INCLUDED IN THE PRIMARY POLICIES? ANY PRIMARY POLICY HAVE REDUCED LIMITS OF LIABILITY OR ELIMINATE COVERAGE FOR SPECIFIC EXPOSURES? PENDING LITIGATION, COURT PROCEEDINGS OR JUDGEMENTS?STATE SUPPLEMENT(S), IF APPLICABLE. ATTACHMENTSREMARKS (ACORD 101, Additional Remarks Section, may be attached if more space is required)AGENCY CUSTOMER ID:Page 4 of 6 ACORD 83 (2012/02)(INITIALS)I SELECT LIMITS LOWER THAN MY BI ACKNOWLEDGE I HAVE BEEN OFFERED THE OPTIONS OF SELECTING UNINSURED MOTORISTS (UM) COVERAGE EQUAL TO THE LIMIT(S) OF MY BODILY INJURY (BI) LIABILITY COVERAGE, OR UM COVERAGE LESS THAN MY BI LIMITS, BUT NOT LESS THAN $25,000 PER PERSON, $50,000 PER ACCIDENT, OR $50,000 COMBINED SINGLE ONLY IN KANSAS:I ACKNOWLEDGE THAT I HAVE BEEN OFFERED UM COVERAGE EQUAL TO MY LIABILITY LIMITS.

8 I HAVE SELECTED THE LIMITS INDICATED IN THIS ONLY IN VERMONT:APPLICABLE ONLY IN LOUISIANA:3. I SELECT UIM LIMITS INDICATED IN THIS I REJECT UIM COVERAGE IN ITS (INITIALS)2. I REJECT UM COVERAGE IN ITS (INITIALS)1. I SELECT UM LIMITS INDICATED IN THIS ACKNOWLEDGE THAT UM COVERAGE AND UNDERINSURED MOTORISTS (UIM) COVERAGE HAVE BEEN EXPLAINED TO ME, AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM AND UIM LIMITS EQUAL TO MY LIABILITY LIMITS, UM AND UIM LIMITS LOWER THAN MY LIABILITY LIMITS, OR TO REJECT UM AND/OR UIM COVERAGE ONLY IN INDIANA, KANSAS, LOUISIANA, NEW HAMPSHIRE AND VERMONTIF THE COMPANY TO WHICH I AM APPLYING OFFERS UNINSURED MOTORISTS (UM) COVERAGE IN MY STATE:APPLICABLE ONLY IN INDIANA:(INITIALS)(INITIALS)2. I REJECT UM COVERAGE IN ITS (INITIALS)1.

9 I SELECT UM LIMITS INDICATED IN THIS ACKNOWLEDGE THAT UM COVERAGE HAS BEEN EXPLAINED TO ME, AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM LIMITS EQUAL TO MY LIABILITY LIMITS, UM LIMITS LOWER THAN MY LIABILITY LIMITS, OR TO REJECT UM COVERAGE ENTIRELY.(INITIALS)APPLICABLE ONLY IN NEW HAMPSHIRE:2. I REJECT UM COVERAGE IN ITS (INITIALS)1. I SELECT UM LIMITS INDICATED IN THIS ACKNOWLEDGE THAT UM COVERAGE HAS BEEN EXPLAINED TO ME, AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM LIMITS EQUAL TO MY LIABILITY LIMITS OR TO REJECT UM COVERAGE ENTIRELY.(INITIALS) date (MM/DD/YYYY)NAMED INSURED'S SIGNATUREPage 5 of 6UM / UIM DISCLOSURESAGENCY CUSTOMER ID:MINNESOTA RESIDENTS SHOULD SUBMIT ACORD 38 MN TO AUTHORIZE RELEASE OF PERSONAL : CREDIT SCORING CANNOT BE USED IN OREGON FOR RENEWALS UNLESS REQUESTED BY THE of the Notice of Information Practices (Privacy) has been given to the applicant.

10 (Not applicable in all states, consult your agent or broker for your state's requirements.) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR Insurance AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR Insurance OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES.