PERSONAL UMBRELLA LIABILITY EXPOSURE ANALYSIS CHECKLIST

(July 2019)

Individual insurance company umbrella applications should contain enough information to properly underwrite and process new business. Umbrella applications used by different companies may vary significantly from each other, depending upon a company’s coverage philosophy. For instance, a company that writes umbrella coverage without requiring any underlying coverage is likely to have a more detailed application than companies that require part or all of the underlying coverage. Why? Companies that write part or all of the underlying coverage would make greater use of their underlying underwriting application or file.

The following checklist may be useful in helping a new umbrella client better determine the amount of insurance that is necessary for adequate coverage. It may also identify a need for tailoring the basis coverage in order to address either a new or existing insured's particular exposures. This form is not intended to be a complete analysis of the hazards or possibilities of loss your insured may face.

GENERAL CLIENT INFORMATION

Named Insured(s) __________________________________________________________________

Mailing Address___________________________________________________________________

Home: Telephone: _____________________

Email: _________________________

Fax: ___________________________

Work: Telephone: ______________________

Email: _________________________

Fax: __________________________

Cell phone numbers:

Named Insured: __________________

Spouse : ________________________

Others: _________________________

Marital Status:

___ Married ___ Single ___ Divorced ___ Separated ___ Widow ___ Other

Describe other:

____________________________________________________________________________________

If married or separated, name of spouse: ___________________________________________________

List below all people whom currently reside in the household. This should include:

Family members
Persons under 21 in the applicant’s care. This includes foster children.
Other residents who are not related. Some examples are significant others, roomers, boarders, tenants, and domestic employees.

Name	Age	Relationship to Applicant	Occupation

List below all family members whom do not currently reside in the household including noncustodial children, college students away at school, or any family who lives in an assisted living / skilled care facility.

Name	Address	Relationship to Applicant

Is any property held in a trust? ___ Yes ___ No

If yes, answer the following:

Trust Name: _________________________________________________________________

Trustee(s): ___________________________________________________________________

Property: ____________________________________________________________________

Is the residence a historical landmark or showcase home? ___ Yes ___ No

If yes, answer the following:

Are tours conducted? ___ Yes ___ No

How many tourists visit annually? _______

What is the maximum number of visitors on a single day? _______

Is the property used for community activities? ___ Yes ___ No

If yes, answer the following:

Describe the activities.

_____________________________________________________________________________

How often is the property used for this purpose? _________

What is the maximum number of visitors who might attend? _______

Does the insured belong to a homeowners or condominium owners association? ___ Yes ___ No

If yes, attach a copy of the Association agreement and bylaws.

Is the residence located in a flood plain? ___ Yes ___ No

If yes, does the insured carry flood insurance? ___ Yes ___ No

Is the residence located in a known earthquake area? ___ Yes ___ No

If yes, does the insured carry earthquake insurance? ___ Yes ___ No

Does the insured carry firearms or have firearms in the residence? ___ Yes ___ No

If yes, please complete the firearms supplement.

Have there been any water-related (including backup of sewers or drains) losses? ___ Yes ___ No

If yes, answer the following:

List items damaged by water that remain in the residence.

_____________________________________________________________________________

Is there any evidence of water leaking or seeping in the residence? ___ Yes ___ No

Are there odors in the residence that could suggest the presence of mold? ___ Yes ___ No

Are there underground or above ground storage tanks on premises? ___ Yes ___ No

Are flammables, chemicals, or fuel stored on the premises? ___ Yes ___ No

If yes, describe the property stored, where it is stored, and procedures to prevent ignition.

____________________________________________________________________________________

Is lead paint in the residence? ___ Yes ___ No

Are chemicals sprayed on the premises? ___ Yes ___ No

If yes, describe is the chemical(s) sprayed and state whether the applicant or contractor does the spraying.

____________________________________________________________________________________

Does the insured own, lease or rent additional residences? ___ Yes ___ No

If yes, build a separate questionnaire for each residence.

Does the insured own rental property? ___ Yes ___ No

If yes, build a questionnaire for rental property.

PERSONAL UMBRELLA

UNDERLYING

List all policies that provide liability coverages for the applicant.

Insurance Coverage	Primary Carrier	*Limits

* Indicate any policies that include annual aggregate limits.

List countries where the applicant and/or family members travel to regularly.

Family member name	Country(ies)

PERSONAL LIABILITY

List all liability exclusions attached to the homeowners or personal liability policy(ies).

____________________________________________________________________________________

List or describe any special liability amendments to the homeowners or personal liability policy(ies).

____________________________________________________________________________________

Is there an owned, hired, or leased watercraft exposure? ___ Yes ___ No

If yes, describe the watercraft, its location, and the duration of the exposure.

____________________________________________________________________________________

Is there an owned, hired, or leased aircraft exposure, including drones? ___ Yes ___ No

If yes, describe the aircraft, its location, and the duration of the exposure.

____________________________________________________________________________________

Are drones registered as required by the FAA? ___ Yes ___ No

What is the annual cost of on-site contracted labor?

$ __________ Yard/Garden/Pool	$ __________ Housekeeping	$ __________ Child Care
$ __________ Additions/Repairs	$ __________ Other

Describe other.

____________________________________________________________________________________

List organizations in which the applicant or family members are officers or directors.

Name	Organization	Title	Term of Service

PROFESSIONAL LIABILITY

List all household members with current professional credentials or licenses.

Name	Credential/License

If any, does the employer provide professional liability coverage?

___ Yes ___ No ____Yes, but only when acting on the employer’s behalf

Do the individuals with professional credentials or licenses purchase professional liability coverage?

___ Yes ___ No

BUSINESS RELATED

Does the applicant conduct any business-related activities on its premises? ___ Yes ___ No

If yes, describe all such activities.

____________________________________________________________________________________

Do commercial business policies cover these activities? ___ Yes ___ No

If yes, provide the named insured on the policy, the carrier, and the limits.

Named Insured	Carrier	Limits

AUTOMOBILE

List all exclusions attached to the personal automobile policy(ies).

____________________________________________________________________________________

List or describe any special amendments to the personal automobile policy(ies).

____________________________________________________________________________________

How many vehicles does the applicant own or lease in the following categories?

Vehicle Type	Vehicle Type	Vehicle Type
____ Private Passenger	____ SUV	____ Pickup Truck
____ Other Types of Trucks	____ Van	____ Bus

Identify the number of operators in each of the following categories.

Types of Operators	Types of Operators	Types of Operators
____ Youthful (16-25)	____ Over 65	____ Suspended license
____ Excluded under Primary	____ Other

Describe other:

____________________________________________________________________________________

RECREATIONAL VEHICLES

List all exclusions attached to the policy(ies).

____________________________________________________________________________________

List or describe any special amendments to the policy(ies).

____________________________________________________________________________________

How many vehicles does the applicant own or lease in the following categories?

Vehicle Type	Vehicle Type	Vehicle Type
____ Motorcycle	____ All-Terrain Vehicle (ATV)	____ Snowmobile
____ Camper	____ Race Car	____ Dune Buggy
____ Personal Watercraft	____ Other

Describe other:

____________________________________________________________________________________

Identify the number of operators in each of the following categories.

Types of Operators	Types of Operators	Types of Operators
____ Youthful (16-25)	____ Over 65	____ Suspended license
____ Excluded under Primary	____ Other

Describe other:

____________________________________________________________________________________

EMPLOYERS LIABILITY

Does the applicant employ domestic staff? ___ Yes ___ No

If yes, answer the following.

Is there a commercial workers compensation policy that covers the employees? ___ Yes ___ No

If yes, provide the named insured on the policy, the carrier, and the limits.

Named Insured	Carrier	Limits

List the name of each individual, the duties performed, if the individual lives on premises, and the number of hours the individual works per week.

Name	Duties performed	Live on premises? (Y/N)	Hours worked per week

What is the annual payroll? $____________________________