BUSINESS OWNERS PROGRAM
MI Umbrella Liability Insurance Quote Request
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No coverage is bound until you are contacted
by one of our representatives.
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1
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Contact Information |
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Name of Business |
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Contact Name: |
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Address: |
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Address 2: |
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City - St - Zip: |
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Phone Number: |
FAX
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E-Mail Address: |
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2
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:Desired Limits: (Each Occurrence /
Policy Aggregate) (other limits may
be available upon request)
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$1,000,000/$1,000,000
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$2,000,000/$2,000,000
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$3,000,000/$3,000,000
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$4,000,000/$4,000,00
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3
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Desired Self-Insured Retention: |
None
$10,000
other
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4
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Current Underlying Insurance
Information Please complete the
table below with the information
from your current underlying
Automobile and Employers’ Liability
policies. |
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5
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Is the business self-insured for
Workers’ Compensation or Employers’
Liability in any states?
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YES
NO
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6
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Is the business subject to any of
the following Workers’ Compensation
laws?
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7
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Has any product, work, accident, or
location been excluded, uninsured or
self-insured from any previous
coverage? |
YES
NO
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If yes, provide details |
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8
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Are any explosives, caustics,
flammables or other dangerous cargo
hauled? |
YES
NO
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9
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Are any passengers transported for a
fee? |
YES
NO
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10
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Are there any autos that are not
insured by an underlying policy?
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YES
NO
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11
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Are any vehicles leased or rented to
others?
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YES
NO
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12
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Is Hired and Non-owned Auto coverage
on an underlying auto policy?
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YES
NO
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13
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What is the auto liability coverage
symbol on the underlying auto
policy? |
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(This information can be found on
your current auto policy’s
Declarations Page.) |
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14 |
Vehicles Used or Owned:
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15 |
Does the business own or use any
Buses, or Heavy or Extra Heavy
Trucks and/or Tractors? |
YES
NO
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If yes, please describe the vehicles
and what they are used for.
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