10
Are any aircraft owned, leased, chartered
or furnished for regular use?
11
Do any drivers have mental or physical impairments?
12
Are any premises, vehicles, watercraft, aircraft used for business?
13
Are any premises, vehicles, watercraft, aircraft owned, hired,
leased or regularly used not covered by the primary policies?
14
Do you engage ina any type of farming operation?
15
Do you hold any non-remunerative positions?
16
Do you employ any residence employees?
17
Any non-owned property exceeding $1,000 in value in your care,
custody or control?
18
Any non-owned business or professional activities included in
the primary policies?
19
Does any primary policy have reduced limits of liability or eliminate
coverage for specific exposures?
20
Was any coverage declined, cancelled or non-renewed within the
past 5 years?
21
Any motorcycles, mopeds or all terrain vehicles owned?
22
Any other business activities conducted from your residence or
premises?
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?
33
If yes, what is the date, amount paid
and description of each loss or claim?
34
What is the liability limit requested?
Select
$100,000
$300,000
$500,000
$1,000,000
Social Security #:
