Insurance Service Center DePere - Umbrella Liability Policy Checklist

Umbrella Liability Policy Checklist
Please read the article below and complete one section or the other accordingly.
Client Name*

First NameLast Name
Email Address
If you DO want an umbrella policy complete this section:
Amount of Coverage Requested: (Please check the amount desired)

$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000
Uninsured and Underinsured Motorist Coverage (UM/UIM) is available on most umbrella policies. By selecting this optional coverage, you would increase your coverage if you are injured by an uninsured or underinsured (someone who has less coverage than you) driver.

Please select one of the following:
Yes, I do want coverage for UM/UIM coverage under my umbrella policy.

Yes
No, I do NOT want coverage for UM/UIM coverage under my umbrella policy.

No
To be properly covered by my umbrella, I understand that all policies must be written with ISC or a copy of the policy must be provided to ISC on an annual basis.

Check box to initial this statement.
Comments
I acknowledge my understanding that coverage for umbrella liability policy does not begin until it has been approved by the home office.
Client Signature
Date

MonthDayYear
If you DO NOT want an umbrella policy complete this section:
- I am aware of what an umbrella liability covers and wish to waive this coverage.
- I am aware that an umbrella liability policy is generally $10 - $20 per month.
- I am aware that an umbrella liability policy is generally $10 - $20 per month.
Comments
By signing below, I am rejecting coverage for an umbrella liability policy and acknowledge that I have read the above disclosures.
Client Signature
Date

MonthDayYear
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