Umbrella Insurance Survey - IRMS Insurance and Risk Management Services

Contact Information

Client Name

Contact Name

First Last

Phone Number

Email Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

How did you find out about IRMS?

Other

Driver/Automobile Information

Current Carrier/Prior Insurance

When do you want your policy to be effective?

Driver #1 Information

Name

First Last

Gender

Marital Status

Date of Birth

Drivers License #

Any Violations/Accidents? (Last 3 Years)

Add a second driver?

Yes

Driver #2 Information

Name

First Last

Gender

Marital Status

Date of Birth

Drivers License #

Any Violations/Accidents? (Last 3 Years)

Add a third driver?

Yes

Driver #3 Information

Name

First Last

Gender

Marital Status

Date of Birth

Drivers License #

Any Violations/Accidents? (Last 3 Years)

Add a forth driver?

Yes

Driver #4 Information

Name

First Last

Gender

Marital Status

Date of Birth

Drivers License #

Any Violations/Accidents? (Last 3 Years)

*Additional documentation may be needed for above.

Type of vehicle

What type of vehicle(s) are you insuring?

Car, Truck, Van or SUV
Motorcycle

Vehicle #1 Information

Vehicle Information

Vehicle Year Vehicle Make

Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Add a second vehicle?

yes

Vehicle #2 Information

Vehicle Information

Vehicle Year Vehicle Make

Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Add a third vehicle?

yes

Vehicle #3 Information

Vehicle Information

Vehicle Year Vehicle Make

Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Add a fourth vehicle?

yes

Vehicle #4 Information

Vehicle Information

Vehicle Year Vehicle Make

Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Residence Information

Number of Residences

Insurance company that currently insures the property

Personal Liability Limit

Location Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is the dwelling description for this property?

What is the occupancy of this property?

Which months during the year do you occupy the property?

If you rent the property, which months during the year do you rent the property?

Is a business operated at this property?

If yes, provide details

Check all that apply to this property

Pool
Jacuzzi
Hot Tub
Spa
Diving Board
Slide
None of These

Do you have any pets or other animals living at this property?

If yes, list type and breed

Have you reported any liability losses in the last 5 years for this property?

Would you like to add a second residence?

Yes

Residence #2 Information

Number of Residences

Insurance company that currently insures the property

Personal Liability Limit

Location Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is the dwelling description for this property?

What is the occupancy of this property?

Which months during the year do you occupy the property?

If you rent the property, which months during the year do you rent the property?

If you rent the property, what is the minimum amount of time (week/months/annually) each renter will occupy the property?

Is a business operated at this property?

If yes, provide details

Check all that apply to this property

Pool
Jacuzzi
Hot Tub
Spa
Diving Board
Slide
None of These

Do you have any pets or other animals living at this property?

If yes, list type and breed

Have you reported any liability losses in the last 5 years for this property?

Would you like to add a third residence?

Yes

Residence #3 Information

Number of Residents

Insurance company that currently insures the property

Personal Liability Limits

Location Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is the dwelling description for this property?

What is the occupancy of this property?

Which months during the year do you occupy the property?

If you rent the property, which months during the year do you rent the property?

If you rent the property, what is the minimum amount of time (week/months/annually) each renter will occupy the property?

Is a business operated at this property?

If yes, provide details

Check all that apply to this property

Pool
Jacuzzi
Hot Tub
Spa
Diving Board
Slide
None of These

Do you have any pets or other animals living at this property?

If yes, list type and breed

Have you reported any liability losses in the last 5 years for this property?

Would you like to add a fourth residence?

Yes

Residence #4 Information

Number of Residents

Insurance company that currently insures the property

Personal Liability Limit

Location Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is the dwelling description for this property?

What is the occupancy of this property?

Which months during the year do you occupy the property?

If you rent the property, which months during the year do you rent the property?

If you rent the property, what is the minimum amount of time (week/months/annually) each renter will occupy the property?

Is a business operated at this property?

If yes, provide details

Check all that apply to this property

Pool
Jacuzzi
Hot Tub
Spa
Diving Board
Slide
None of These

Do you have any pets or other animals living at this property?

If yes, list type and breed

Have you reported any liability losses in the last 5 years for this property?

Other Exposure Information

Do you own any tracts of undeveloped land?

If yes, how many acres?

Who currently insures the undeveloped land?

If yes to above, provide the current limit of liability

Are you a member of a Board of Directors?

If yes, provide the name of the current carrier

If yes, provide the current limits

Watercraft #1 Information

Watercraft Information

Watercraft Year Watercraft Make Watercraft Model Watercraft Length

Watercraft Horsepower

Watercraft Maximum Speed

Current Insurance Carrier

Current Limits

Add second watercraft?

Yes

Watercraft #2 Information

Watercraft Information

Watercraft Year Watercraft Make Watercraft Model Watercraft Length

Watercraft Horsepower

Watercraft Maximum Speed

Current Insurance Carrier

Current Limits

Recreational Vehicle Information

Do you own any recreational vehicles?

Who currently insures the RV?

Provide the current limits of liability.

Do you own any off road vehicles?

Provide the name of the current carrier

Provide the current limits

Coverage Information

Limit of Liability

Do you have Excess Uninsured Motorist Coverage?

Optional Limit

Any Additional Comments

By Checking this Box, you certify that all information provided is accurate.*

Are you currently a client of IRMS?*

If yes, who is your agent?*

If no, have you spoken to any of the following agents?*

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