Umbrella Inurance

Umbrella Insurance

Kelly & Co., Inc.

Request for Homeowners Insurance Quote

Umbrella coverage gives you a layer of liability coverage above your auto, homeowners, rental dwelling coverage, and RV (cycle, motor home, etc.), up to the limit you select. Standard policy is a $1 Million liability limit; but we also have policies available at $2 Million and $5 Million. Fill in ALL fields below:

PERSONAL INFORMATION

First Name:

Last Name:

Street Address

City

State

Michigan

Zip code

County

Contact Phone

Fax Number

Your E-mail address

Primary Policy Holders Birth Date:

Spouses Birthdate

CURRENT ADDRESS:

Street Address

City

State

Zip code

DWELLING INFORMATION

Number of Dwellings You Own and Occupy

Total UNIT Count of all Rental Dwellings

Number of Autmobiles You Own

Number of RV's You Own,

VEHICLE OPERATORS INFORMATION:

Number of Drivers:

List Ages of All Drivers:

Driving Records Clear:

COVERAGE INFORMATION:

Limit of Coverage:

Underlying Auto Limits

Underlying Homeowners Limits

CURRENT INSURANCE INFORMATION

Are you Currently Insured by Another Company?

If yes, Insurance Carrier Name:

Number of Years:

PRIOR CLAIMS INFORMATION:

Prior Claims:

Describe Prior Insurance Claims:

Claim History in Last 5 Years (Include all claims)

Underlying Rental Dwelling Limits

Rentals must have $500,000 liability INCLUDING Personal Injury Coverages:

COMMENTS OR QUESTIONS

Please Enter Any Comments or Questions

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..............	Kelly & Co., Inc 2575 S Van Dyke Rd, Suite 102 Marlette, MI 48453	Marlette: 800.257.3735 989.635.2649 Fax: 989.635.3744	Kingston: 888.843.3388 989.683.2419 Fax: 989.683.3107	Kelly & Co., Inc 5951 State Street, Kingston, MI 48741