Insurance Specialists, Inc.
 
MEMBERS
  PRODUCTS & SERVICES
   
PERSONAL UMBRELLA INSURANCE PROGRAM
Program Highlights
Required Insurance
Pricing & Payments
Application
FAQs

Application
Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* Please complete the below application in its entirety.

Application
Your Full Name:
Street Address:
City:
State:     Zip:
Phone:  
Contact E-mail Address:
Organization/Association*: 

   
Number of Youthful drivers in your Household:

(Defined as individuals under age 21 living in your house and holding a valid Driver's License.)
 

When would you like coverage to start?:

Enrollments are monthly beginning the 15th of each month.
 
Are you a regionally or nationally elected official OR a nationally known celebrity?
Yes No  
 

Has any Member of your household had a major driving violation (i.e., DUI, Reckless Driving, etc.) or a license suspension in the past 3 years?  
Yes No  

 

Select Liability Limit & Pricing:
 

Please check to confirm that you currently have (and will maintain) the Required Underlying Insurance.
   

By checking the box to the left, you verify that all of your representations on this application are true and accurate to the best of your knowledge.
   
Please check the box to the left to confirm that you have been advised by the originating insurance producer and you understand that this policy is underwritten by an Excess & Surplus lines insurer and that an Excess and Surplus lines insurer is not subject to the filing or approval requirements of the Department of Banking and Insurance.  Such a policy may contain conditions, limitations, exclusions and different terms than a policy issued by an insurer granted a Certificate of Authority by the Department of Banking and Insurance.

Please click the "Submit Application" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.


 
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