ACORD 131 — Commercial Umbrella/Excess

1 · Policy Header

Date

Producer

Customer ID

Insurer (Carrier)

NAIC Code

Named Insured

Policy Number

Policy Effective Date

Status

New Renew

Policy Type

Umbrella Excess

Trigger

Occurrence Claims Made

Transaction

Voluntary Other

Other Transaction Description

Prior Coverage Policy #

Proposed Retroactive Date

Current Retroactive Date

2 · Limits & Coverage

Umbrella Each Occurrence

$

Deductible / Retention

$

First-Dollar Defence

Other Coverage Description (A)

Limit (A)

$

Other Coverage Description (B)

Limit (B)

$

Employee Benefits Liability

Each Employee Limit

$

Aggregate Limit

$

Deductible / Retention

$

Retroactive Date

Program Name

3 · Locations & Exposures

Up to six locations. Empty rows are skipped.

#	Loc ID	Location Name	Address	City	St	Zip	Operations	Payroll	Receipts	Foreign Sales	Empl.

4 · Schedule of Underlying Insurance

Automobile

Insurer

Policy #

Effective

Expiration

Mod Factor

CSL — Each Accident

$

BI — Per Person

$

BI — Per Accident

$

PD — Per Accident

$

Premium — CSL

$

Premium — BI

$

Premium — PD

$

General Liability

Insurer

Policy #

Effective

Expiration

Mod Factor

Trigger

Occurrence Claims Made

Each Occurrence

$

General Aggregate

$

Products / Completed Ops

$

Personal & Advertising

$

Fire — Rented Premises

$

Med Exp — Each Person

$

Premium — Prem/Ops

$

Premium — Products

$

Premium — Other

$

Employers Liability

Insurer

Policy #

Effective

Expiration

Mod Factor

EL — Each Accident

$

EL — Disease/Employee

$

EL — Disease/Policy

$

Premium

$

Other Underlying Policies

#	Type	Insurer	Policy #	Effective	Expiration	Coverage	CSL	Premium	Mod
A
B

GL Form Edition Date

GL Tail Coverage Effective Date

GL Claims-Made Retroactive Date

GL Uninterrupted Coverage Since

5 · Underwriting Questions

Have any products/work/accident locations been excluded or uninsured?

Tail coverage purchased on any prior primary/excess policy?

ACD / ACE / ACF question codes

ACD Yes

6 · Underlying Coverages & Exposures

Check both columns where applicable: Cov. = afforded under underlying policy; Exp. = exposure exists.

Coverage	Cov.	Exp.	Description / Other

Underlying Coverage Notes

7 · Loss History

No prior losses

#	Date	Line of Business	Occurrence Description	Paid	Reserved

8 · Care, Custody & Control

Location ID

Property Value

$

Occupied Area

Property Description

Other Liability Description

Indicators

Real property Personal property Insured held harmless Waiver of subrogation Named insured on fire policy

9 · Vehicle Fleet

Class	Owned	Non-Own	Leased	Property Hauled	Local	Intermed.	Long

10 · Operations & Advertising

Advertisers Liability — Media Used

Annual Advertising Cost

$

Services of an advertising agency used?

Any coverage provided under agency policy?

Applicant own / lease / operate aircraft?

Explosives / caustics / flammables / dangerous cargo hauled?

Passengers carried for a fee?

Any units not insured under underlying policies?

Any vehicles leased / rented to others?

Hired & non-owned coverage provided?

Bridge / dam / marine work performed?

Contractors

Work Contracted Description

Agreement Description

11 · Subcontractors, Self-Insured & Medical

Applicant own / rent / use cranes?

Subcontractors carry coverage less than applicant?

Applicant self-insured in any state?

Hospital or first-aid facility maintained?

Coverage provided for doctors / nurses?

Employers Liability Extensions

Indicators

Jones Act FELA Stop Gap Other

Other Description

Malpractice

Doctors

Nurses

Beds

12 · Pollution, Products & Aircraft

EPA Identifier

GL with Pollution Exclusion Sudden & Accidental Only GL with Pollution Coverage Separate Pollution Coverage

Current/past products contain hazardous materials?

Missiles/engines/guidance systems used in aircraft?

Product-liability loss past 3 years?

Products — Gross Sales

Tier A

$

Tier B

$

Tier C

$

Independent Contractors Description (Protective Liability)

13 · Watercraft & Property Rating

Watercraft

#	Loc ID	Owned	Length	Horsepower
A
B

Property Rating

#	Loc ID	Stories	Apartments	Pools	Diving Boards
A
B

14 · Remarks

15 · UM / UIM / MedPay & Signatures

Uninsured Motorists Limit

$

Underinsured Motorists Limit

$

Medical Payments Limit

$

Named Insured Initials (UM/UIM/MedPay rejection)

Initials A

Initials B

Initials C

Initials D

Signatures

Producer Name (Print)

Producer Signature

State Producer License No.

National Producer Number

Named Insured Signature

Signature Date