Umbrella Insurance Quote Form

(Personal and Commercial)

Welcome to Weber Insurance's Umbrella quote form.  To request a quote, please complete as much of the form as possible.  Use the Tab key to move from field to field.  If you leave the form, use the back button on your browser to return to the form.  This form will be emailed to us.  All information entered is confidential.

DO NOT USE THE "ENTER" KEY

USE THE "TAB" KEY  

OR YOUR MOUSE

TO MOVE FROM FIELD TO FIELD.
 

 

 
Contact Information
Your Name:  
Date of Birth:  
 Mailing Address:  
City:  
State:  
Zip Code:  
Daytime phone:  
Evening Phone:
FAX:
Email Address:

 

Homeowners Insurance Coverage

HO Policy Carrier Name 

Liability Limits 

Rental/Vacation Policy Carrier Name 

Liability Limits 

 

List All Rental and Vacation Properties Owned and Number of Units in Each
Properties

Property #1

 Property #2 Property #3 Property #4
Address
Number of Units

 

TOTAL NUMBER OF UNITS (including Primary Home)

 

Auto Insurance Coverage

Auto Policy Carrier Name 

Liability Limits 

 

Vehicles Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Year:
Make (Acura)
Model (Integra GS)

 

Driver Information
Drivers

Driver #1

 Driver #2 Driver #3 Driver #4
First Name
Date of Birth (mm/dd/yy)
Martial Status
Gender M    F M     F M     F M     F

An Insurance Score is required for an accurate quote.  Please call us at 215-860-0400 if you do not wish to provide your SS# over the internet.
Drivers License #
# of Yrs Licensed

Describe tickets and license suspensions

Example: Driver #1 - 12/99 Speeding - going 75 in a 55 zone
Tickets in last 5 yrs.

Describe accidents with date and amount of damage your insurance company paid

Example: #1-12/99, I hit other driver in rear, my company paid $7,500
Accidents in last 5 yrs.

 

List  All Liability Claims made in the last five years

What is the name of your present insurance company?
Type of  claim:     
Date of Claims:   

Amount Paid by Insurance $  

Details of claims:  

 During the past 5 years, has any coverage been cancelled, non-renewed, declined, or placed in non-standard markets (non-standard markets charge tax)

Yes     No

 

 

 

Remarks

 

 Be patient, it will take some time for the information to be processed.  A Form Confirmation will be displayed.  Please review the information you entered.  If you need to correct any information, use the "Back" arrow on your browser to return to the form with the data you entered still in the form.  Clicking on "Return to the Form" will erase all data and return you to an empty form.

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

Are you ready to send this information? (type "YES")