Liability Umbrella – Brightway Quotes

Name *

First

Last

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

1. How many motorized vehicles licensed for road use in your household? *

2. How many residential properties in your household? *

3. How many watercraft, OTHER than personal watercraft (WaveRunners, Jet Skis, etc.), are in your household? *

4. How many personal watercraft (Jet Skis, WaveRunners etc.) in your household? *

5. What is the total number of drivers? (Include drivers with a learner's permit or valid driver's license) *

6. How many drivers are under the age of 22? (Include drivers with a learner's permit) *

7. How many drivers are age 70 and over? *

7a. Are any drivers age 80 or older? *

8. How many moving violations have ALL drivers had within the last 3 years? Include DWI/DUI violations within the last 5 years. *

9. How many at-fault accidents have all drivers had in the last 3 years? *

10. How many antique, classic and/or collectible vehicles are in your household? *

11. How many residential properties owned or rented by you or any member of your household are located outside U.S. (including U.S. territories and possessions), Canada, or Puerto Rico? *

12. How many acres of land owned or leased (including partial ownership)? *

13. How many drivers have been licensed less than one year, have a learner's permit, or have a non- U.S. driver's license? *

14a. How many driving incidents have all drivers ages 21 and under had within the last 3 years?

14b. How many driving incidents have all drivers ages 80 and over had within the last 3 years? *

15. How many alcohol/drug related driving incidents have all drivers had in the last 5 years?

16. Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving with at least 4 points assigned, negligent driving and/or had a driver's license suspended (for reasons other than driving under the influence of alcohol or drugs), revoked or refused in the last 5 years? *

Yes
No

17. Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years? *

Yes
No

18. Do you or any member of your household have an occupation of a professional entertainer, athlete, or media personality? *

Yes
No

19. Have you or any member of your household had a liability loss greater than $50,000 in the past 5 years or is there any open liability claim or lawsuit pending against you or any member of your household? *

Yes
No

20. Does any other member of your household or person residing in your household have a Personal Umbrella policy with RLI Insurance Company other than this policy? *

Yes
No

21. Has any one driver had more than 3 moving violations within the last 3 years? (Include DWI/DUI incidents within the last 5 years) *

Yes
No

22. Has any one driver ages 21 and under and/or 80 and over had more than one driving incident within the past 3 years? *

Yes
No