Excess/Umbrella Liability Quote Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Excess Liability Information

General Liability Exposure

General Liability Limits *

General Liability Pure Premium (excluding taxes and fees) *

General Liability Policy Expiration Date *

Is the primary General Liability written on an occurrence basis? *

Gross annual receipts for all operations *

Description of operations *

Professional Liability Exposures

Do you have professional liability exposure? *

Auto Liability Exposures

Do you have Commercial Auto Liability insurance? *

DO you have Garage Liability? *

Do you have Hired/Non-Owned Auto Liability ONLY? *

Auto Liability Premium (Do not include PIP, UM, or physical damage coverages; show liability premium ONLY.) *

Auto Liability Limits *

# of light trucks or PP cars traveling within a 0-50mi radius? *

# of light trucks or PP cars traveling within a 51-200mi radius? *

# of medium trucks traveling within a 0-50mi radius? *

# of medium trucks cars traveling within a 51-200mi radius? *

Employers Liability Exposures

Do you HAVE Workers Compensation/Employers Liability Insurance? *

Employers Liability Limits *

Underwriting Information

Any excess/umbrella liability losses in the last 5 years? *

Any auto, general liability, or employers liability losses exceeding $100,000 in the last 5 years? *

ANY LOSS involving assault, battery, abuse or molestation? *

Umbrella or excess liability policy cancelled or non-renewed in the last 5 years? *

How did you hear about us? *

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Insurance Websites Designed and Hosted by Insurance Website Builder

Toll Free: 1-844-595-3313\|Local: 713-655-0335\|Fax: 832.834.4261	2201 Caroline\|Houston, TX 77002
Home\| Our Products\| About Us\| Refer A Friend\| Contact Us
© 2021 United National Insurance Agency