Comprehensive Personal Liability Application Form printable pdf download

Comprehensive Personal Liability Application (page 1)

1) Applicant(s): ___________________ 2) Address: ___________________________________________

3) Profession / Occupation: _______________________________________________

4) Has the applicant or any other member of the household been employed as any of the following: professional athlete;

entertainer; media personality; reporter; author; journalist; coach in the NBA, NFL, MLB, NHL or College Division I

Football or Basketball; Owner of a professional sports team; CEO, CFO or COO of a Fortune 500 Company; Director or

Producer with major television of motion picture credits; a generally recognizable public figure; or has the applicant or any

other member of the household been elected or appointed public official at the state or federal level? __ Yes __ No

5) Has the applicant has more than one loss in the past three years? ___ Yes ___ No

Limits and Term

6) Policy Period From ________/_______/_______ to _______/_______/______

Limits of Insurance [ ] $50,000 [ ] $100,000 [ ] $300,000 [ ] $500,000 [ ] $1,000,000

7) Schedule of locations to be covered

Owner

Rental

Address: List only locations to be covered Dwelling or Vacant Land Pool Occupied Dwelling Mobile Home

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Comprehensive Personal Liability Application Form