AMR Insurance - Tacoma, Washington - Business Umbrella Quote

Business Umbrella Quote

Name of Business
Contact Name:
Address:
Mailing Address:
City, State, Zip
Phone Number	Home Work
Email
Location for this quote.(Address)

:Desired Limits: (Each Occurrence / Policy Aggregate) (other limits may be available upon request)

$1,000,000/$1,000,000	$2,000,000/$2,000,000	$3,000,000/$3,000,000
$4,000,000/$4,000,00

Desired Self-Insured Retention:

None $10,000 Other

If Other

	Carrier/Policy #	Effective Date (M/D/Y)	Expiration Date (M/D/Y)
Automobile Liability
Employers’ Liability (Workers Compensation)

Is the business self-insured for Workers’ Compensation or Employers’ Liability in any states?

YES NO

Is the business subject to any of the following Workers’ Compensation laws?

Jones Act	FELA	Stop Gap
Federal Coal Mine Health and Safety Act	US Longshoremen’s and Harbor Workers Compensation Act

Has any product, work, accident, or location been excluded, uninsured or self-insured from any previous coverage?

YES NO

If yes, provide details

Are any explosives, caustics, flammables or other dangerous cargo hauled?

YES NO

Are any passengers transported for a fee?

YES NO

Are there any autos that are not insured by an underlying policy?

YES NO

Are any vehicles leased or rented to others?

YES NO

Is Hired and Non-owned Auto coverage on an underlying auto policy?

YES NO

What is the auto liability coverage symbol on the underlying auto policy?

(This information can be found on your current auto policy’s Declarations Page.)

Type	# Owned or leased	Property Hauled? If yes, Describe	Radius of Use
Private passenger			0-50 MI	50-200 MI	Over 200 MI
Trucks
Light 0 – 10,000 lbs. GVW			0-50 MI	50-200 MI	Over 200 MI
Medium 10,001 – 20,000 lbs. GVW			0-50 MI	50-200 MI	Over 200 MI

Does the business own or use any Buses, or Heavy or Extra Heavy Trucks and/or Tractors?

YES NO

If yes, please describe the vehicles and what they are used for.

* Required Fields