#205 -15252 32 Avenue, Surrey, BC V3Z 0R7 Ph:604-522-8870 Fax: 604-522-8891

www.guardianrisk.com

2019-11

Personal Umbrella Policy Application

Qualifying Questions This Personal Umbrella policy does not provide coverage in certain circumstances; please respond to the following questions in order to determine if you will qualify for this Coverage.

Is the principle location outside of Canada? If yes, we will not be able to provide quote.

No Yes

Is the applicant involved in professional media activities or high-profile occupations such as broadcasting, advertising, journalism, writing, professional entertainer?

No Yes

Underlying Insurer?

If underlying Residential Policy is written by another company than listed above, please specify below:

Do you personally own any commercial or public use vehicles?

No Yes

Applicant Details

Full Name

Date of Birth

Occupation

Address (including postal code)

Have you had a personal insurance policy declined, cancelled or refused in the last 5 years?

No Yes

Have you or any member of your household been sued for libel and slander?

No Yes

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Required Coverage

Proposed Effective date

Required Limit

Automobiles, Motorcycles & Recreational Vehicles

Automobiles Motorcycles

Motor Homes Snowmobiles

All Terrain Vehicles Trail Bikes

Go Karts Other

Number of Autos (excluding motorcycles) owned by the applicant to be insured hereunder:

How many underlying Automobile Policies do you have?

Do the underlying Automobile Policies cover all vehicles?

No Yes

Is Family Protection Endorsement/Uninsured Motorist Protection required?

No Yes

Has the applicant or members of his/her household had more than one at-fault accident in the past 3 years?

No Yes

Number of drivers with less than 5 years experience to be insured hereunder

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Has the applicant or members of his/her household had any convictions for dangerous driving, impaired driving, drug use or criminal negligence in the past 5 years?

No Yes

Are any of the vehicles to be insured located outside Canada or the United States?

No Yes

Residential Locations

Number of Canadian residential locations owned by the applicant

How many of these are rental units and for which coverage is required under this policy?

Number of residential locations owned by the applicant in the United States and to be insured hereunder

How many Underlying Residential Policies do you have?

Does the applicant have any residences outside of Canada and the United States of America for which coverage is required under this policy?

No Yes

Does Underlying Personal Liability Insurance Cover all Locations?

No Yes

This Personal Umbrella Liability Policy does not cover business or professional exposures; however, we will provide excess liability coverage for incidental office type exposures at your residence

Is there any business or professional exposure other than incidental office exposure at your residence?

No Yes

If yes please provide details below:

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Watercraft

Does the Applicant own or operate Watercraft and for which coverage is required under this policy?

No Yes

If yes please provide – Type, Length, HP, Speed, current underlying policy, area of operations, whether used for pleasure or business and if used for any racing, speed tests, parasailing or powered by jet propulsion:

Underlying Liability Policies

Please enter details of any underlying Auto Policies below:

Please enter details of any underlying General Liability Policies below:

Are all Underlying Policies in the Applicant's name?

No Yes

If No, please provide details:

Do any of the above policies have any special restrictions, reduced limits of liability or eliminate coverage with respect to any insured exposure?

No Yes

If Yes, please provide details:

Policy #1:

Policy #2:

Policy #3:

Policy #4:

Policy #5:

Policy #6:

Policy #1:

Policy #2:

Policy #3:

Policy #4:

Policy #5:

Policy #6:

Sep.2017

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Loss Information

Has the applicant or any resident of the household experienced any liability loss in the last 5 years which has been paid or reserved in an amount of $50,000 or more?

No Yes

If Yes, please provide details below:

APPLICANT CONFIRMATION

The undersigned warrants that the information declared on this application is correct at that no material facts have been suppressed or misrepresented

Completion of this application does not bind Underwriters to complete the insurance. It is agreed however that this application shall form the basis of the contract should coverage be granted by the Underwriters.

Signature:

Date:

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