Personal Umbrella Liability Insurance Quote Form by McGrath Insurance Group
To receive a quote, please fill out the form below.....
Name....:
Address:
City:   State:    Zipcode: 
Phone Number(s):
E-Mail Address:
How many motorized vehicles in your household?
How many motorcycles in your household?
How many antique, classic and/or collectible vehicles are owned by you or any member of your household?
How many residential properties in your household?
How many watercraft, other than canoes, jet skis and waverunners, are owned or regularly operated by you or any member of your household?
How many jet skis in your household?
How many drivers?
Has the applicant or any resident of the applicant’s household been convicted of or plead guilty to a felony in the past five years?
Has the applicant or any resident of the applicant’s household had a liability loss greater than $ 50,000 in the past five years or is there an open liability claim or lawsuit pending against them?
Are any locations used as rooming houses, student housing other than a college dormitory room, assisted living facilities or group home facilities?
Are any locations to be included subsidized housing?
Is there a pool at any location that is either unfenced or has a diving board or waterslide?
Does the applicant or any resident of the applicant’s household operate any business or conduct any professional activities that are covered by primary policies at any location to be covered?
Are any locations leased to others for hunting, fishing or other sporting or recreational purposes?
Does the applicant or any resident of the applicant’s household own any exotic pets?
Is there a dog exclusion on any primary homeowners or comprehensive personal liability policy?
Is there an animal exclusion on any primary homeowners or comprehensive personal liability policy?
Does any household operator have any restriction on his/her driver’s license other than glasses or corrective lenses? NOTE: Any “Yes” response requires submitting a completed L252R Physicians Medical Statement.
Is there currently, or during the next 12 months will there be, any construction, renovation or demolition at any residential 1-4 family residence or condominium owned by or rented to the applicant?
What are your current Automobile Insurance Bodily Injury Liability Limits?
Personal Liability Limit (Homeowners)
Drivers in the Household
Driver Name Birth Date License # Moving Violations
(Last 3 Years)		 * Major Moving Violations At Fault Accidents
(Last 3 Years)		 Drug/Alcohol Related Offenses
(Last 5 Years)
* Major moving violations include, but not limited to, speeding 25MPH over, evading the police, leaving the scene, vehicular homicide, driving under a suspended license & reckless driving)

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474 (FAX) 327-7911
Toll Free: 1-800-977-2999