Commercial Excess

For Faster service on your commercial excess accounts complete the form below and hit the "Continue" button. Your submission will be electronically delivered to the next available underwriter.

Applicant Name: Applicant Web Address: Applicant telephone number: Description of Risk: Requested Limits: Any prior losses in the last five years?

If yes, include five years hard copy loss runs with submission.

Current Carrier Information

Carrier Name: ( If Applicable) Policy Number: ( If Applicable) Effective Date: (If Applicable)

Named Insured Primary Address and Subsidiaries

Name: Location: Description: Annual Payroll: Gross Sales: Number of Employees:

Underlying Insurance Information

Automobile:

Carrier/Policy Number: Effective Date:

Expiration Date:

Limits: (CSL, BI, PD) Premium

General Liability:

Carrier/Policy Number: Effective Date:

Expiration Date:

Limits - Each Occurance: Aggregate Limit: Premium:

Employers Liability:

Carrier/Policy Number: Effective Date:

Expiration Date:

Limits: (CSL, BI, PD) Premium: Has the applicant had any policies or coverage's cancelled or non renewed in the past three years? Has the applicant had a prior bankruptcy in the past seven years?

Agency Information:

Contact Person: Phone Number: E-Mail: