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Asia Insurance Business Umbrella Quote

Customer Information
Business Name
First Name	Middle Initial	Last Name
Street #	Street Name	Apt or Unit
City	State	Zip	-
Home Phone	Work Phone	Email

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

Current Underlying Insurance Information
Please complete the table below with the information from your current underlying Automobile and Employers’ Liability policies.
	Carrier/Policy #	Effective Date	Expiration Date
Automobile Liability
Employers’ Liability (Workers Compensation)
Limits
CSL		$
BI		$
PD		$
Each Accident		$
Disease Policy Limit		$
Disease Each Employee		$
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.)
Vehicles Used or Owned
Type	# Owned or leased	Any Property Hauled? If yes, Describe	Radius of Use
			0-50 MI	50-200 MI	200 MI+
Private passenger
Trucks/Light 0-10,000 lbs. GVW
Trucks/Med. 10,001-20,000 lbs. GVW
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.

Please use the space below to add comments regarding any special circumstances or coverage needs

Disclosure

Where permitted by law, the insurance companies we quote will individually confirm your information through consumer reports, which may include credit reports. Each company will provide the source of the report if you are interested. Your information may be shared with the quoting company's affiliated underwriting companies, independent representatives or other insurance partners.

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