28 Route 6A
Sandwich, MA 02563

Fax: 508-833-0909

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Personal Umbrella

You don’t have to be a millionaire to be sued like one. Million-dollar judgments against individuals for negligence aren’t so rare anymore. Unfortunately receiving a lawsuit with a million-dollar demand has become more common. If you receive such a court summons and you have only $100,000, $300,000 or even $500,000 of coverage, you may lose a lot of sleep.

Umbrella policies offer inexpensive “peace of mind” for most types of negligence claims. Automobile accidents are probably the most common source of serious claims. This policy supplements your basic automobile liability with extra million-dollar layers of protection. It also covers other types of catastrophic claims such as a neighbor’s child drowning in your pool or the delivery man being seriously injured by falling over your child’s toys.

First Name*

Last Name*

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number*

Best Time To Call

Time

Email Address*

Any Driver with Mental - Physical Impairments?

Yes

Any Premises, Vehicles, Watercraft, Aircraft Used for Business?

Yes

Do You Engage in Any Type of Farming Operation?

Yes

Do You Hold Any Non-Remunerative Positions?

Yes

Any Aircraft Owned, Leased, Chartered or Furnished for Regular Use?

Yes

Do You Employ Any Residence Employees? (i.e. Housekeeper)

Yes

Any Non-Owned Property Exceeding $1,000 in Value in Your Care, Custody or Control?

Yes

Any Non-Owned Business or Professional Activities Included in the Primary Policies?

Yes

Does Any Primary Policy Have Reduced Limits of Liability or Eliminate Coverage for Specific Exposures?

Yes

Was Any Coverage Declined, Cancelled or Non-Renewed within the Past 5 Years?

Yes

Any Motorcycles, Mopeds or All Terrain Vehicles Owned?

Yes

Any Youthful Drivers Under the Age of 25?

Yes

Any Other Business Activities Conducted from Your Residence or Premises?

Yes

Please Explain Any "Yes" Answers from Above

Driver #1 (Name, Year's Licensed, Relation, DOB, Sex, Marital Status, Driver's Education (yes or no))

Driver #2 (Name, Year's Licensed, Relation, DOB, Sex, Marital Status, Driver's Education (yes or no))

Driver #3 (Name, Year's Licensed, Relation, DOB, Sex, Marital Status, Driver's Education (yes or no))

Driver #4 (Name, Year's Licensed, Relation, DOB, Sex, Marital Status, Driver's Education (yes or no))

Driver #1 History (Driver Name, Date, Type of Conviction, Fines $, mph over limit)

Driver #2 History (Driver Name, Date, Type of Conviction, Fines $, mph over limit)

Driver #3 History (Driver Name, Date, Type of Conviction, Fines $, mph over limit)

Driver #4 History (Driver Name, Date, Type of Conviction, Fines $, mph over limit)

Driver #1

License Suspended

Revoked

DUI Conviction for Alcohol

Conviction for Drugs

Driver #2

License Suspended

Revoked

DUI Conviction for Alcohol

Conviction for Drugs

Driver #3

License Suspended

Revoked

DUI Conviction for Alcohol

Conviction for Drugs

Driver #4

License Suspended

Revoked

DUI Conviction for Alcohol

Conviction for Drugs

Car #1 (Year, Make, Model, Body Type)

Car #2 (Year, Make, Model, Body Type)

Car #3 (Year, Make, Model, Body Type)

Car #4 (Year, Make, Model, Body Type)

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The Insurance Company of Cape Cod, Inc. · 28 Route 6A
Sandwich · MA 02563