10
Are any aircraft owned, leased, chartered
or furnished for regular use?
Yes
No
11
Do any drivers have mental or physical impairments?
Yes
No
12
Are any premises, vehicles, watercraft, aircraft used for business?
Yes
No
13
Are any premises, vehicles, watercraft, aircraft owned, hired,
leased or regularly used not covered by the primary policies?
Yes
No
14
Do you engage ina any type of farming operation?
Yes
No
15
Do you hold any non-remunerative positions?
Yes
No
16
Do you employ any residence employees?
Yes
No
17
Any non-owned property exceeding $1,000 in value in your care,
custody or control?
Yes
No
18
Any non-owned business or professional activities included in
the primary policies?
Yes
No
19
Does any primary policy have reduced limits of liability or eliminate
coverage for specific exposures?
Yes
No
20
Was any coverage declined, cancelled or non-renewed within the
past 5 years?
Yes
No
21
Any motorcycles, mopeds or all terrain vehicles owned?
Yes
No
22
Any other business activities conducted from your residence or
premises?
Yes
No
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?
Yes
No
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 #: