Personal Umbrella Insurance • California Apartment Association

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Name*
The named insured may be a maxiumim of two individuals, provided both individuals reside in the same household. This policy cannot be issued in the name of an estate, trust or LLC.
First Last
Primary Residence Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address
If different from Primary Residence Address.

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

Applicant's Brokering Agent Number
Date*
MM slash DD slash YYYY
Premium $*
Coverage Limit Desired*
Please choose one.
- $5 Million
- $3 Million
- $2 Million
- $1 Million

See this page for definitions and question details.
Questions 1-9
Carefully read questions 1 through 9 and respond by clicking the right number. If any question is unanswered or answered in the "Not Eligible" column, the risk is not eligible.
Question 01
How many motorized vehicles licensed for road use (i.e., motor homes, motorcycles, cars, etc.) are owned, leased, rented, or regularly operated by you or any member of your household? (Do not count antique, classic or collectible vechicles. See question 10.)
Preferred (please enter 0, 1, 2, or 3) Standard (please enter 4) *Standard 2 (please enter 5 or 6) **PUP Special $1Mill Max (please enter 7, 8, 9, or 10) Not Eligible (please enter 11 or more)
Question 02
How many residential properties are owned or rented by you or any member of your household? 1-4 family units are eligible and should be counted as one property. do not include residential properties that are covered under a commercial general liability Polcy or other non personal premises liability policy since they are excluded from coverage.
Preferred (please enter 0 or 1) Standard (please enter 2, 3, or 4) *Standard 2 (please enter 5 or 6) **PUP Special $1Mill Max (please enter 7, 8, 9, or 10) Not Eligible (please enter 11 or more)
Question 03
How many watercraft, between 14 and 45 ft and with a maxmum speed of 50 mph are owened or regularly operated by you or any member of your household? watercraft exceeding these limitations are excluded from coverage. ( do not count canoes, jet skis, waverunners or other personal watercraft. see question 4.)
Preferred (please enter 0) Standard (please enter 1 or 2) *Standard 2 (please enter 3) **PUP Special $1Mill Max Not Eligible (please enter 4 or more)
Question 04
How many jet skis, waverunners or other personal watercraft are owned or regularly operated by you or any member of your household?
Preferred (please enter 0) Standard (please enter 1 or 2) *Standard 2 (please enter 3) **PUP Special $1Mill Max Not Eligible (please enter 4 or more)
Question 05
What is the total number of drivers? (include drivers with a lerner's permit.)
Preferred (please enter 0, 1, or 2) Standard (please enter 3, 4, 5, or 6) *Standard 2 **PUP Special $1Mill Max (please enter 7 or 8) Not Eligible (please enter 9 or more)
Question 06
How many drivers are under the age of 22? (Include any member of your household with a learner's permit or driver's license and see the definition of "driver" on page 5.)
Preferred (please enter 0) Standard (please enter 1 or 2) *Standard 2 (please enter 3 or 4) **PUP Special $1Mill Max Not Eligible (5 or more)
Question 07
How many drivers are age 70 or over? Note: ths response is not considered when determining the rating tier for applicatns in maine (Include any member of your household with a driver's license.)
Preferred (please enter 0) Standard (please enter 1, 2, 3 or 4) *Standard 2 **PUP Special $1Mill Max Not Eligible (5 or more)
Question 08
How many moving violations have all drivers had within the last 3 years? (Include DWI/DUI incidents within the last 5 years or 3 years in MT.) (See question 28.)
Preferred (please enter 0) Standard (please enter 1 or 2) *Standard 2 (please enter 3 or 4) **PUP Special $1Mill Max (please enter 5 or 6) Not Eligible (7 or more)
Question 09
How many at-Fault accident have all drivers in your household had in the last 3 years? (see question 28.)
Preferred (please enter 0) Standard (please enter 1) *Standard 2 (please enter 2) **PUP Special $1Mill Max (please enter 3) Not Eligible (4 or more)
*if there are drivers age 70 or over AND an answer to question 8 or 9 falls under the standard II (N/A in HI) or the PUP special column, the risk is not eligible. ** $1 Million is the ONLY available limit for PUP special.

Question 26: carefully read Question 26 and respond by checking "yes" or "no". if left unanswered or checked "no," the risk is not eligible.
Question 26
Do you and ALL members of your household agree to maintain the MINIMUM REQUIRED LIMITS OF LIABILITY coverage outlined below as a condition of coverage? for those limits that currently do not apply dto you or any member of your household, you must agree to maintain those limits only if they become applicable to you or any member of your household during the policy period as a condition of your coverage.
- Yes
- No
Primary residence only- requires homeowners or comprehensive personal liability

SEASONAL, SECONDARY OR RENTAL PROPERTIES REQURIE PREMISES LIABILITY OR COMPREHENSIVE PERSONAL LIABILITY

300,000 per occurrence

Note: residential properties that are covered under a commercial or other non-personal premises liability policy are excluded from coverage.
FARMOWNERS OR FARM COMPREHENSIVE PERSONAL LIABILITY
(required only if you or any member of your household own a farm which is not covered by your homeowners policy)

300,000 per occurrence

UNLICENSED RECREATIONAL VEHICLES (including snowmobiles, atvs, golf carts, etc.)

(required only if you r a member of your household own or acquire an unlicensed recreational vehicle during the policy period that is not covered by your homeowners or personal liability policy for the following limits of liability.)

100,000 combined single limit per occurrence ($325,000 in texas)
OR
100,000/300,000/25,000
WATERCRAFT
(including boats, personal watercrafts, jet skis and canoes)

(required only if you or a member of your household own or acquire a watercraft during the policy period that is not covered by your homeowners or personal liability policy for the following limits of liability.)

300,000 combined single limits
or
$250,000/$500,000/$100,000
or
$300,000/$300,000/$100,000

Note: the RLI personal umbrella does not provide coverage for waterraft exceeding 45ft and/or 50mph. this exclusion does not apply to personal watercraft.
If you are unsure what underlying coverage limits you are carrying, or are required to carry, we suggest contacting your local brokering agent.

QUESTION 27 Carefully read question 27 and respond by selecting one limit (A,B, or C) in the box provided. you MUST agree to maintain one of the three limits outlined in question 27, regardless of whether you currently own, lease, rent or operate a vehicle. if left unanswered, the risk is not eligible.
Question 27
Which of the following MINIMUM REQUIRED LIMITS OF AUTOMOBILE LIABILITY do you and all members of your household agree to maintain as a condition of coverage for all licensed vehicles, that are owned, leased, rented, operated or acquired during the policy period? if you elect to purchase Excess Uninsured/Under insured Motorist (UM/UIM) coverage the Required Basic UM/UIM Policy Limits must be equal to the liability limits for the Required Basic Automobile Liability Policy. You agree that this condition applies equally to personal use of a vehicle covered under a Commercial Automobile Liability Policy.
- A
- B
- C
LIMIT A
500,000 bodily injury per person/
$500,000 Bodily Injury per occurrence/
$ 50,000 property damage per occurrence
or
$500,000 combined single limit per occurrence

Limit A is ALWAYS REQUIRED if there are drivers under the age of 22 in the household
OR
if the answer to question 15 is >0
OR
in KS, and MA if there are drivers with six years or less driving experience in the household.
LIMIT B
$250,000 Bodily injury per person/
$500,000 Bodily Injury per occurrence/
$50,000 Bodily injury per occurrence
OR
$300,000 Bodily injury per person/
$300,000 Bodily injury per occurrence/
$50,000 Property damage per occurence
OR
$300,000 Combined single limit per occurrence (325,000 in texas)
LIMIT C
100,000 Bodily injury per person/
$300,000 Bodily injury per occurrence/
$50,000 property damage per occurrence

The choice of limit c results in a higher premium

excess UM/UIM is not available if you maintain Limit C
Limits B and C are available options ONLY if all drivers in the household are age 22 and over. Limit C is NOT available if there are any drivers age 70 or over in the household; and/or if any response makes the risk standard II (N/A in HI); and/or if any response makes the risk PUP Special.

If you are unsure what underlying coverage limits you are carrying, or are requred to carry we suggest contacting your local brokering agent.

QUESTION 28: complete the following for all members of your household age 14 and older. Also include on this list any other person who operates a vehicle owned, leased, rented or regularly operated by you or a member of your household at least 50% or more of that vehicle's use.
List
Full Name D.O.B Licensed<br>Permit Y/N Licensed<br>Permit # State Relation to app Number of violations 3 yrs (incl. DWI/DUI 5yrs/3yrs MT) Number of At-Fault Accidents (3yrs) DWI/DUI Y/N
IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: I understand that as a part of the underwriting procedure, a consumer report may be prepared. Such reports may include information regarding my driving record, credit history, general reputation, personal characteristics and mode of living. I herby consent to the preparation of such reports and the disclosure of such reports to RLI Insurance Company and the producer of record. I understand that these reports will be handled in the strictest confidence, and that information as to the nature and the scope of these reports will be provided to me upon request.

FRAUD WARNING: any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil penalties.

APPLICANT STATEMENT: The information given on this application is true and complete to the best of my Knowledge. I understand that any omission or misstatement of fact in the information given voids the policy. I agree that I will acquire and maintain Minimum Required Limits of Liability for all additional exposures (drivers, houses, vehicles, watercraft, etc.) if they become applicable during the policy period. The insured's Brokering Agent shall not have the right to make, alter, modify, or discharge any contract or policy issued on the basis of this Application. I understand that the application and prepayment of premium must be accepted by RLI Insurance Company.
I UNDERSTAND THIS APPLICATION IS NOT A BINDER and NO INSURANCE WILL BE IN EFFECT UNTIL RLI INSURANCE COMPANY ISSUES A POLICY. THE APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT'S ORIGINAL SIGNATURE. A Power of Attorney letter must accompany the application, where applicable.

Full Name	D.O.B	Licensed<br>Permit Y/N	Licensed<br>Permit #	State	Relation to app	Number of violations 3 yrs (incl. DWI/DUI 5yrs/3yrs MT)	Number of At-Fault Accidents (3yrs)	DWI/DUI Y/N

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Questions 1-9