Chubb Insurance MGA

QUOTE REQUEST

 

Agency Contact Name:  
Agency Contact Email:  
Agency Name:  
Agency Phone#:  
Agent Comments/Notes on Account:


Insured Name:  
Insured DOB:  
Insured Phone# (Home):              (Work)#:  
Occupation:  
Job Title:  
Company:  
If Retired List Prior Occupation:  
 
Spouse's Name:  
Spouse's DOB:  
Spouse's Occupation:  
Spouse's Job Title:  
Spouse's Company:  
If Retired List Prior Occupation:  
 
Present Carrier:  
Expiration Date:  
Non-Renewed/Details:  
Loss History: Claims/Accidents/Violations:  



HOMEOWNERS QUOTE SHEET

Type of Dwelling:             Condo      House      Townhouse      Renters
Risk Location:
Mailing Address (If different than location):
Dwelling Limit/Additions & Alterations:   Contents/Personal Property:  
Liability:   Deductibles:  
Standard    Deluxe Occupancy:  
If Secondary - Rented to Others:   Yes        No
Year Built:  

PROTECTION
Within 5 Miles From Fire Department:   Yes        No *
Within 1,000 Feet From Hydrant:   Yes        No *
* Fire questionnaire required if one of above is "No"
Roof Shape:  Roof Material: 
Square Feet:   Construction Type: 
Flood Zone:    If "A" Flood Zone, elevation certificate with positive elevation will be required.
Burglar Alarm: Central Station  Yes        No
Fire Alarm: Central Station:   Yes        No
Sprinkler System:   Yes        No
Gated Community:   Yes        No
Guarded:   Yes        No
Distance From Water:   Cross Street:  
Updates to Electrical/PlumbingGuarded:  
  (If Yes, list Year)     

Yes        No

TEXAS HOMEOWNERS ONLY
Rate Level:   Protection Class:  
No of Families: (1-4)  Type of Roof:       
Within City Limits:   Yes        No
Swimming Pool:   Yes        No
Farmers Liability:   Yes        No
Endorsements Requested:   Yes        No



VALUABLE ARTICLE QUOTE SHEET

Jewelry:  Amount       Coverage Type:    Itemized    Blanket
Value of Single Highest Item:  Amount
In-vault:  Amount
Fine Arts:  Amount       Coverage Type:    Itemized    Blanket
Furs:  Amount       Coverage Type:    Itemized    Blanket
Camera/Others:  Amount       Coverage Type:    Itemized    Blanket
In-Vault Information: (Please provide bank address)

REQUIREMENT: Appraisals required for items over $50,000.
Items over $10,000 need to be itemized.




AUTOMOBILE QUOTE SHEET

AUTOMOBILES
VEH
No
YEARMAKEMODELVIN/SYMBOLUSAGE
1
2
3
4


VEHICLE GARAGE LOCATIONS
Vehicle 1:
Vehicle 2:
Vehicle 3:
Vehicle 4:


COVERAGES
CoverageVEH#1 VEH#2 VEH#3VEH#4
Liability Limit
UM/UIM
Stacked (S) or Non-stacked (N) S     N S     N S     N S     N
PIP
ADD'L PIP
Coll Deductible
Comp Deductible
Interested Party Loss Payee Yes     No Yes     No Yes     No Yes     No
Roadside Coverage Yes     No Yes     No Yes     No Yes     No
Alarms Yes     No Yes     No Yes     No Yes     No
Anti-Lock Brakes Yes     No Yes     No Yes     No Yes     No


DRIVERS
Driver NameDate of BirthLicense#Vehicle #
1 
2 
3 
4 
5 



EXCESS LIABILITY QUOTE SHEET

Excess Liability Limit:      UM at $1,000,000: Yes    No

# OF RESIDENCES:
Residence #1
Residence #2

Rental?   Yes    No
Residence #3

Rental?   Yes    No
Residence #4

Rental?   Yes    No


NUMBER OF VEHICLES:
YEARMAKEMODEL
Corporate Car:    Yes    No
Underlying Automobile Liability Limit:  


NUMBER OF WATERCRAFT:
YEAR MAKE MODELLENGTHHP/SPEED
 
WATERCRAFT #1 #2#3#4
Hull ID  
No of Engines  
Fuel  
Type of Boat  
Inland or Coastal  
Agreed Value