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Umbrella Insurance

GEDMINAS INSURANCE and FINANCIAL SERVICES

This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Umbrella insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.

* Required Information

Umbrella Fact Finding Questions

In regards to your insurance, what is most important to you?	Price
	Service
	Proper Coverage

Approximately, when was the last time you did a review with your agent?	Within the year
	Over 2 years ago
	Over 5 years ago
	Never

Please rate the following in the order that you feel are most important for you to protect?	Income:
	Auto:
	Savings:
	Home:
	Other:

In the event of a lawsuit, accident, or judgment would you want to:	Maximize Protection
	Assume Some Risk

In the event of an untimely death, is it important to you that your surviving spouse and/or children maintain the quality of life you currently have together without debt?	Yes No

Would you be interested in combining your home and auto insurance for additional savings up to 45%?	Yes No

Would you be interested in mortgage cancellation insurance?	Yes No

Personal Information

First Name

Last Name

Gender

Male Female

Date of Birth

Marital Status

Occupation

Home Address

Zip Code

Best Time to Call

Best Phone Number To Reach You At

Fax

* Email Address

Single Family Dwellings Owned:

Autos Owned:

RV Owned:

Multi-Unit Buildings Owned:

Vacant Property Owned:

Motorcycles Owned:

Underwriting Information

Are any aircraft owned, leased, chartered or furnished for regular use?	Yes No

Do any drivers have mental or physical impairments?	Yes No

Are any premises, vehicles, watercraft, aircraft used for business?	Yes No

Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies?	Yes No

Do you engage in any type of farming operation?	Yes No

Do you hold any non-remunerative positions?	Yes No

Do you employ any residence employees?	Yes No

Any non-owned property exceeding $1,000 in value in your care, custody or control?	Yes No

Any non-owned business or professional activities included in the primary policies?	Yes No

Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?	Yes No

Was any coverage declined, cancelled or non-renewed within the past 5 years?	Yes No

Any motorcycles, mopeds or all terrain vehicles owned?	Yes No

Any other business activities conducted from your residence or premises?	Yes No

If yes, Please explain.

Current Coverage Information

Current Umbrella Insurance Company

Losses and Claims for the Last 5 years?	Yes No

If yes, what is the date, amount paid and description of each loss or claim.

Liability Limit:

Additional Information, Comments, Recommendations: