Submit Excess Insurance Risk

Insured Information

Insured Name

DBA (if applicable)

Contact Name

Contact Email

Contact Phone

Business Website

Years in Business

FEIN/Tax ID

Mailing Address

City

State

ZIP Code

Type of Business

Business Description

Underlying Policies

Please provide information about your underlying policies

Auto Liability Policy

Insurance Carrier

Policy Limit

Effective Date

Expiration Date

Annual Premium ($)

Deductible ($)

General Liability Policy

Insurance Carrier

Policy Limit

Effective Date

Expiration Date

Annual Premium ($)

Deductible ($)

Excess Coverage Information

Requested Effective Date

Expiration Date

Excess Limit Requested

Current Excess Carrier (if any)

Current Excess Premium ($)

Current Excess Limit

Operations Information

Total Number of Vehicles

Total Number of Drivers

Operating Radius (miles)

States of Operation

Annual Mileage

Annual Revenue ($)

Claims History

Number of Claims in Last 5 Years

Total Incurred Amount ($)

Largest Claim Amount ($)

Brief Description of Largest Claim

Document Upload

Upload Loss Runs (5 years)

Drag and drop your loss runs here or click to browse

Upload Current Auto Declarations Page

Drag and drop your auto declarations page here or click to browse

Upload Current GL Declarations Page

Drag and drop your GL declarations page here or click to browse

Upload Current Excess Declarations Page

Drag and drop your excess declarations page here or click to browse

Upload Vehicle Schedule

Drag and drop your vehicle schedule here or click to browse

Upload Additional Documents

Drag and drop additional documents here or click to browse

Submit Excess Insurance Risk

Insured Information

Underlying Policies

Auto Liability Policy

General Liability Policy

Excess Coverage Information

Operations Information

Claims History

Document Upload

Additional Comments