excess um/uim overview 1-1-2011 3-1-2011 · excess um/uim overview v1 10/14/2010 excess um/uim...

Excess UM/UIM Overview v1 10/14/2010

Excess UM/UIM Overview

I. Excess UM/UIM will be available for new and renewal policies or endorsements

effective:

1-1-2011 in Alabama, Arkansas, Arizona, Colorado, D.C., Delaware, Florida, Georgia,

Idaho, Iowa, Indiana, Kansas, Louisiana, Maine, Michigan, Minnesota, Missouri,

Mississippi, Nevada, New Hampshire, New Mexico, North Dakota, Ohio, Oklahoma,

Oregon, South Dakota, Tennessee, Utah, Vermont, Virginia, West Virginia, Wisconsin.

2-1-2011 in California, Connecticut, Hawaii, Maryland, Massachusetts, Montana,

Nebraska, North Carolina, Pennsylvania, Rhode Island, Texas, Washington, and

Wyoming.

3-1-2011 in Kentucky and South Carolina

Approval pending in Alaska, Illinois, New Jersey, New York

II. Excess UM/UIM Coverage form for most UM/UIM states PUP325C (01/11)

a. Used in most new Excess UM/UIM states

b. State specific forms filed in NY, IL, NJ, OH, AK

c. Coverage form in current 7 states did not change

III. New Business

a. New Business App –UM PUP276 (01/11)

i. Required in any state where RLI offers UM/UIM (voluntary or mandated)

b. New Business App – Non UM PUP276 NUM (01/11)

i. Suggested in any state where RLI does not offer UM/UIM and will be

accepted for a short time in current 7 along with their state mandated

form.

ii. PUP 276 (09/09) will be acceptable only in states where UM/UIM is NOT

available and the current 7 for some period.

c. New Business Dec – UM PUP301 (04/10) added the word “Excess”

i. Rules changed such that Excess UM/UIM box shows for all policies

ii. State specific decs filed in MA, SC, TX

Excess UM/UIM Overview v1 10/14/2010

IV. Renewal Business

a. 2 processes: 1) Old 7 UM states-UM/UIM not available and 2) new UM/UIM

states (process does not change for old 7 and states where not yet available at all)

b. Purchase/Rejection form PUP261 (01/11)

c. Renewal Cover letter – QRN12 (03/10) Other

d. Renewal Cover letter – Voluntary –QRN12 (01/11)

e. Renewal Questionnaire – PUP207 (09/10)

i. Used in current 7 UM states and any not available state—current process

works/nothing changes on these renewals

f. Renewal Questionnaire – Voluntary—PUP207 (01/11)

i. Used in only voluntary states this renewal since never had coverage before

g. Renewal Policy Form – Cover Letter—PUP118 (01/11)

i. Used only in states where UM/UIM is now approved

V. Billing—Billing language will not confirm endorsement is done—simply a bill

a. Renewal Billing – PUP601 (01/11)

b. Revised Renewal Billing PUP620 (01/11)

c. Endorsement Billing – PUP605 (01/11)

d. Change Acknowledgement –PUP330 (01/11)—new process

e. Endorsement Requested but never paid PUP722 (01/11)-- new process

VI. Webinar Training Any/All Admins

a. www.rlipersonalumbrella.com/excessum

b. Webinar invite

http://www.rlipersonalumbrella.com/excessum

1) PART III – WHAT WE WILL DO is amended by the addition of the following:

D. Excess Uninsured/Underinsured Motorist Coverage.

a) We will pay those sums which you or your Relatives shall become legally entitled to recover from anuninsured or underinsured motorist for bodily injury in excess of all underlying insurance up to and not toexceed the Excess Uninsured/Underinsured Motorists Limit of Coverage shown on the Declarations.

b) We will pay under Excess Uninsured/Underinsured Motorists Coverage only after the policy limits of any andall other underlying insurance have been exhausted by payment of judgments or settlements.

c) You and your Relatives must maintain underlying Uninsured Motorist Coverage and Underinsured MotoristCoverage at limits equal to or greater than the Minimum Limits of Coverage as shown in the Required BasicPolicies section of the Declarations for such coverages. We will be liable for damages for Bodily Injuryresulting from a Loss only in excess of such Minimum Limits of Coverage and any other collectibleinsurance. Failure to maintain the Required Basic Policies at the Minimum Limits of Coverage equal to orgreater than those listed for Uninsured Motorist and/or Uninsured Motorist under section B. of theDeclarations eliminates coverage under this Excess Uninsured/Underinsured Motorist Coverage.

2) PART IV WHAT IS NOT COVERED – EXCLUSIONS is amended by replacing Exclusion K., as follows:

K. No-fault benefits to you or anyone else entitled to coverage under this policy. “No-fault” refers to benefits paidwithout regard to fault or legal liability.

3) All other exclusions included in PART IV – WHAT IS NOT COVERED – EXCLUSIONS shall apply to the coverageprovided by this endorsement.

4) PART IV – WHAT IS NOT COVERED – EXCLUSIONS is amended to include the following additional exclusionswith respect to the coverage provided by this endorsement:

a) Damages for bodily injury, any part of which is not covered by underlying insurance affording in total theMinimum Limits of Coverage equal to those listed for Uninsured/Underinsured Motorist under section B. of theDeclarations.

b) Damages for bodily injury otherwise payable under Excess Uninsured/Underinsured Motorists Coverage if suchdamages or any portion thereof are included in a settlement or agreement between an insured, a legalrepresentative of an insured or an insurer acting on behalf of any insured which is entered into without our priorwritten consent.

c) Damages for bodily injury if there was no physical contact between you or your Relative or between your oryour Relative’s motor vehicle and the uninsured/underinsured motor vehicle.

d) Damages for bodily injury if the Loss was not reported to the police, sheriff or other similar governmentalauthority within twenty-four (24) hours after the accident.

Personal Umbrella Liability Policy Provisions

EXCESS UNINSURED/UNDERINSURED MOTORIST ENDORSEMENT

RLI Insurance CompanyPeoria, Illinois 61615

A Stock Insurance Company

Page 1 of 2PUP 325C (01/11)

Policy Number:

This endorsement modifies insurance under the following:

e) Punitive or exemplary damages.

f) Property damage to any property, whether covered by underlying insurance or not.

g) Duplicate payments for the same elements of loss under Part III A (1) of this policy and under this ExcessUninsured/Underinsured Motorist Coverage endorsement.

h) Any bodily injury which is also covered under any workers’ compensation, unemployment compensation, nonoccupational disability, occupational disease, disability benefits law or any similar law, or any changes oramendments thereto.

5) With respect to the coverage provided by this endorsement PART VI – CONDITIONS is amended to include thefollowing additional conditions:

P. Limit of Insurance. This Excess Uninsured/Underinsured Motorists Coverage is limited to the ExcessUninsured/Underinsured Motorists Limit of Coverage shown on the Declarations regardless of the number ofpolicies, persons covered, covered automobiles, recreational vehicles, insureds, premiums paid, claims made, orvehicles involved in any accident. The Limit of Coverage shown on the Declarations for ExcessUninsured/Underinsured Motorist Coverage is the most we will pay for all damages resulting from any one Loss.

Q. If requested, any injured party requesting coverage under this Excess Uninsured/Underinsured Motorists Coverageshall submit to an independent medical examination at our expense by physicians of our choice, as often as wereasonably require.

R. If requested, any injured party requesting coverage under this Excess Uninsured/Underinsured Motorists Coverageshall authorize us to obtain medical records or other pertinent information.

S. If requested, any injured party requesting coverage under this Excess Uninsured/Underinsured Motorists Coverageshall agree to submit to examinations under oath or written questions at our request as often as we reasonablyrequire. In the event of written questions, an injured party’s answers must be signed.

6) Solely for the purpose of this endorsement, PART I – DEFINITIONS is amended to include the following:

Underlying insurance means the Required Basic Uninsured/Underinsured Policy as shown in the Declarations andany other applicable liability, uninsured and/or underinsured motorist coverage, and any bond.

Loss means an accident, including continuous or repeated exposure to the same general harmful conditions.

7) PART II – WHO IS COVERED – INSUREDS does not apply to this Coverage.

8) PART III – (A), (B) and (C) do not apply to this Coverage.

All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and takes effecton the effective date of your policy unless another effective date is shown.

Page 2 of 2

Attached to and forming a part of the policy of RLI Insurance Company.All other terms and conditions of the policy remain unchanged.

PUP 325C (01/11)

NEW BUSINESS

(The named insured may be a maximim of two individuals, provided both individuals reside in the same household. This policy cannot be issued in the name of an estate, trust or LLC.)

* If there are drivers age 70 or over AND an answer to questions 8 or 9 falls under the Standard II (N/A in HI) or the PUP Specialcolumn, the risk is not eligible.

** $1 Million is the ONLY available limit for PUP Special.

7. How many drivers are age 70 or over? Note: This response is not considered whendetermining the rating tier for applicants in Maine. (Include any member of yourhousehold with a driver's license).

8. How many moving violations have all drivers had within the last 3 years? (IncludeDWI/DUI incidents within the last 5 years or 3 years in MT.) (See question 28).

9. How many at-fault accidents have all drivers in your household had in the last 3years? (See question 28).

Page 1 of 5 pages PUP 276 (01/11)

Name

PrimaryResidence Address

City State Zip

Mailing Address (if different from Primary Residence Address)

Address

City State Zip Phone ( ) -E-mail:

QUESTIONS1-9

Carefully read questions 1 through 9 and respond by circling thecorrect number. If any question is unanswered or answered in the"Not Eligible" column, the risk is not eligible. Preferred Standard

*StandardII

NotEligible

1. How many motorized vehicles licensed for road use (i.e., motor homes,motorcycles, cars, etc.) are owned, leased, rented, or regularly operated by you orany member of your household? (Do not count antique, classic or collectiblevehicles. See question 10.)

4. How many jet skis, waverunners or other personal watercraft are owned or regularlyoperated by you or any member of your household?

6. How many drivers are under the age of 22? (Include any member of your house-hold with a learner's permit or driver's license and see the definition of "driver" onpage 5.)

PERSONAL UMBRELLA LIABILITY INSURANCE APPLICATION

ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATIONMUST BE INITIALED BY THE APPLICANT.

5. What is the total number of drivers? (Include drivers with a learner's permit.)

2. How many residential properties are owned or rented by you or any member of yourhousehold? 1-4 family units are eligible and should be counted as one property. Donot include residential properties that are covered under a Commercial GeneralLiability Policy or other non-personal Premises Liability Policy since they areexcluded from coverage.

3. How many watercraft, between 14 and 45 ft. and with a maximum speed of 50 mph,are owned or regularly operated by you or any member of your household?Watercraft exceeding these limitations are excluded from coverage. (Do not countcanoes, jet skis, waverunners or other personal watercraft. See question 4.)

Please fully complete and print the Application, obtain the insured's signature and forward it to your Program Administrator for processing.

**PUPSpecial

($1 Mill Max)

See page 5 for definitions and question details.

PUP 276 (01/11)______

_____________________________

0 1 2 3 4 5 6 7 8 9 10 11 or more

0 1 2 3 4 5 6 7 8 9 10 11 or more

0 1 2 3 4 or more

0 1 2 3 4 or more

0 1 2 3 4 5 6 7 8 9 or more

0 1 2 3 4 5 or more

0 1 2 3 4 5 or more

0 1 2 3 4 5 6 7 or more

0 1 2 3 4 or more

RLI Insurance Company

Requested Effective Date Premium

$5 Million $3 Million $2 Million $1 Million

Coverage Limit Desired:

Applicant's Brokering Agent Number

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Application version to be used ONLY in Excess UM/UIM states as of the introduction date.

17. Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years? YES NO


19. Have you or any member of your household had any personal liability or personal auto bodily injury liability claims forwhich payment by your insurance company exceeded $25,000 in the last 5 years?

16. Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving (with 4 points inFL), negligent driving and/or had a driver's license suspended (for reasons other than driving under the influence of alcoholor drugs), revoked or refused in the last 5 years or 3 years in MT? (Careless or negligent driving N/A in SC)

18. Do you or any member of your household have an occupation of a professional entertainer or athlete, media personality,or an appointed or elected federal or state political figure? (N/A for political figures in FL, OR and TX.)

YES NO

YES NO

YES NO

QUESTIONS10 - 15

Print the response clearly on the line provided. If the question is unanswered or the response is greater than the maximum numberindicated, the risk is not eligible. PUP Special charge(s) apply if any answer to questions 11 through 15 is greater than 0 (or greaterthan 640 for question 12).

QUESTION25

Carefully read the information below and respond to Question 25. Note an additional form is required in the states of FL, IN, LA,NH, VT, WI and WV as outlined below.

PURCHASE

20. Does any other member of your household or other person residing in your household have a Personal Umbrella policywith RLI Insurance Company other than this policy? YES NO

21. Do you or any member of your household own (including partial ownership) 6 or more residential properties rented toothers that are not occupied in whole or in part at any time by you or any member of your household? 1-4 family units areeligible and should be counted as one property. YES NO


10. How many antique, classic and/or collectible vehicles are owned by you or any member of your household? (Max. of 25)

11. How many residential properties owned or rented by you or any member of your household are located outside of the U.S. (includingits territories and possessions), Puerto Rico or Canada? (Max. of 5)

12. How many acres of timberland and/or land that is farmed, for which the liability coverage is provided by a Homeowners, Farmowners orFarm Comprehensive Personal Liability Policy do you or any member of your household own or lease (including partial ownership)?(Max. of 1280)

13. How many drivers have been licensed to drive in the U.S. less than one year, currently have a learner's permit, and/or have a non-U.S.driver's license? A year or more with a learner's permit does not qualify as a year with a driver's license. (Max. of 8)

14. How many driving incidents have all drivers ages 20-21 and/or age 80 or over had within the last 3 years? (Max. 1 per driver)

QUESTIONS16 - 24 Read and respond by checking "Yes" or "No". If any question is unanswered or checked "Yes", the risk is not eligible.

15. How many arrests, citations or license suspensions for driving under the influence of alcohol/drugs, driving while intoxicated and/or anyother alcohol/drug related incidents have all drivers had in the last 5 years or 3 years in MT? (Max. 1 per household for drivers betweenages 22 and 79; 0 per household for drivers under ages 22 and 80 or over.)

22. Has any one driver had more than 3 moving violations in the last 3 years? (Include DWI/DUI incidents within the last 5years or 3 years in MT.) YES NO

23. Has any driver under the age of 20 had a driving incident within the last 3 years? YES NO24. Has any one driver ages 20-21 or age 80 or over had more than one driving incident within the past 3 years? YES NO

EXCESS UNINSURED/UNDERINSURED MOTORIST (UM/UIM) COVERAGE: Excess UM/UIM coverage is offered for anadditional premium. Required Basic UM/UIM policy limits must be equal to the liability limits for the Required Basic Automobile Liability Policy.For residents of FL, IN, LA, NH, VT, WI or WV you must submit the referenced state mandated form.

FL and WV: If you elect to purchase this coverage, you are required to accept this coverage in writing and pay the additional premium. If youaccept UM/UIM coverage you must complete and return form PUP257B in FL or forms PUP547A and PUP547B in WV.

VT: Matching limits of UM/UIM are available for an additional premium. If you elect to reduce the UM/UIM limits to the statutory minimum of$100,000, you must complete and return form PUP257D. Receipt of the applicable form by the company will result in a reduction in the premium.

WI: Limits of $100,000/$300,000 of UM, UIM or both UM/UIM are available for an additional premium. If you reject UM, UIM or UM/UIMcoverage, you must complete and return form PUP248A. Receipt of the applicable form by the company will result in a reduction in the premium.

IN, LA and NH: If you elect to reject UM/UIM coverage you must complete and return form PUP257A in IN and NH and PUP517 in LA. Receiptof the applicable form by the company will result in a reduction in the premium.

All Other States: Excess UM/UIM coverage is offered at a limit of $1 million and an additional premium must be paid. No other form is required.

REJECT25. Do you elect to purchase or reject Excess UM/UIM coverage? (select one)

Residents of FL, IN, LA, NH, VT, WI and WV: Submission of a state mandated form supersedes any response youmay make to this Question 25.

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State mandated form is still required in original seven Excess UM/UIM states.

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No form is necessary for the newly approved Excess UM/UIM states. It only needs to be answered on the application.

QUESTION27

Carefully read Question 27 and respond by selecting one limit (A, B, or C) in the box provided. You MUST agree tomaintain one of the three limits outlined in question 26, regardless of whether you currently own, lease, rent or operatea vehicle. If left unanswered, the risk is not eligible.

27. Which of the following MINIMUM REQUIRED LIMITS OF AUTOMOBILE LIABILITY do you and all members of yourhousehold agree to maintain as a condition of coverage for all licensed vehicles, that are owned, leased, rented, operated oracquired during the policy period? If you elect to purchase Excess Uninsured/Underinsured Motorist (UM/UIM) coverage theRequired Basic UM/UIM Policy Limits must be equal to the liability limits for the Required Basic Automobile Liability Policy.You agree that this condition applies equally to personal use of a vehicle covered under a Commercial Automobile Liability Policy.

OptionA, B, or C

Selected Below

$500,000 Bodily Injury per person/$500,000 Bodily Injury per occurrence/

$ 50,000 Property Damage per occurrence-OR-

$500,000 Combined Single Limit per occurrence

Limit B


$50,000 Property Damage per occurrence-OR-

$300,000 Bodily Injury per person/ $300,000 Bodily Injury per occurrence/


$300,000 Combined Single Limit per occurrence($325,000 in Texas)

Limit C


$ 50,000 Property Damage per occurrence

If you are unsure what underlying coverage limits you are carrying, or are required to carry, we suggest contacting your local brokering agent.

The choice of Limit C results in a higher premium.

Excess UM/UIM is not availableif you maintain Limit C.


Please be sure to sign application on page 4.

Limits B and C are available options ONLY if all drivers in the household are age 22 and over.Limit C is NOT available if there are any drivers age 70 or over in the household; and/or if anyresponse makes the risk Standard II (N/A in HI); and/or if any response makes the risk PUPSpecial.

Limit A is ALWAYS REQUIRED if there aredrivers under the age of 22 in the household

-OR-If the answer to question 15 is >0

-OR-In KS and MA, if there are drivers with six

years or less driving experience in thehousehold.

Limit A


QUESTION26

Carefully read Question 26 and respond by checking "Yes" or "No". If left unanswered or checked "No," the riskis not eligible.

26. Do you and ALL members of your household agree to maintain the MINIMUM REQUIRED LIMITS OF LIABILITY coverageoutlined below as a condition of coverage? For those limits that currently do not apply to you or any member of your household,you must agree to maintain those limits only if they become applicable to you or any member of your household during the policyperiod as a condition of your coverage.

YES NO

IndicateResponse

Below

PRIMARY RESIDENCE ONLY - REQUIRESHOMEOWNERS OR COMPREHENSIVE

PERSONAL LIABILITY

$300,000 per occurrence

SEASONAL, SECONDARY OR RENTALPROPERTIES REQUIRE PREMISESLIABILITY OR COMPREHENSIVE

PERSONAL LIABILITY


FARMOWNERS OR FARMCOMPREHENSIVE PERSONAL LIABILITY

(Required only if you or any member of yourhousehold own a farm which is not covered

by your homeowners policy.)


UNLICENSED RECREATIONAL VEHICLES(Including snowmobiles, ATVs, golf carts, etc.)

(Required only if you or a member of yourhousehold own or acquire an unlicensed recreational

vehicle during the policy period that is not covered by your homeowners or personal liability

policy for the following limits of liability.)


-OR- $100,000/$300,000/$25,000

WATERCRAFT(Including boats, personal watercraft,

jet skis and canoes)

(Required only if you or a member of yourhousehold own or acquire a watercraft during the

policy period that is not covered by yourhomeowners or personal liability policy for the

following limits of liability.)

$300,000 Combined Single Limits-OR-

$250,000/$500,000/$100,000-OR-

$300,000/$300,000/$100,000

NOTE: The RLI Personal Umbrella does notprovide coverage for watercraft exceeding

45 ft and/or 50 mph. This exclusion does notapply to personal watercraft.


NOTE: Residential properties that are covered under a commercial or othernon-personal premises liability policy

are excluded from coverage.

A B C

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of 5 pages PUP 276 (01/11)

APPLICANT STATEMENT: The information given on this application is true and complete to the best of my knowledge. I understand that anyomission or misstatement of fact in the information given voids the policy. I agree that I will acquire and maintain Minimum Required Limits ofLiability for all additional exposures (drivers, houses, vehicles, watercraft, etc.) if they become applicable during the policy period. The insured'sBrokering Agent shall not have the right to make, alter, modify, or discharge any contract or policy issued on the basis of this Application. Iunderstand that the application and prepayment of premium must be accepted by RLI Insurance Company.

IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: I understand that as a part of the underwritingprocedure, a consumer report may be obtained or an investigative consumer report may be prepared. Such reports may include information regardingmy driving record, credit history, general reputation, personal characteristics and mode of living. I hereby consent to the preparation of such reportsand the disclosure of such reports to RLI Insurance Company and the producer of record. I understand that these reports will be handled in thestrictest confidence, and that information as to the nature and the scope of these reports will be provided to me upon request.

DATE APPLICANT'S ORIGINAL SIGNATURE:

APPLICANT'S BROKERING AGENT'S SIGNATURE:

APPLICANT'S BROKERING AGENCY'S NAME:

APPLICANT'S BROKERING AGENCY'S ADDRESS:

APPLICANT'S BROKERING AGENT'S LICENSE ID #:

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerning anymaterial fact thereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil penalties.

ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATION MUST BE INITIALED BY THE APPLICANT.THE SAME VERSION DATE MUST APPEAR ON ALL 4 PAGES OF THE APPLICATION.

I UNDERSTAND THIS APPLICATION IS NOT A BINDER and NO INSURANCE WILL BE IN EFFECT UNTIL RLIINSURANCE COMPANY ISSUES A POLICY. THE APPLICATION WILL NOT BE ACCEPTED WITHOUT

APPLICANT'S ORIGINAL SIGNATURE.A Power of Attorney letter must accompany the application, where applicable.

A PREMIUM CHECK MUST ACCOMPANY THE APPLICATION TO COMPLETE PROCESSING.

(FL Requirement: This application is in compliance with Section 626.752, Florida Statutes. A copy has beenfurnished to the applicant and coverage is Not Bound.)


Full Name (First, MI, Last)

QUESTION28

Complete the following for all members of your household age 14 and older. Also include on this list any other person whooperates a vehicle owned, leased, rented or regularly operated by you or a member of your household at least 50% or more of thatvehicle's use.

Date of Birth

Licensed or Permit?

Y/N

Drivers Licenseor

Permit Number StateRelationship to

ApplicantDWI/DUI

Y/N

At-FaultAccidents

(3 yrs)

Violations 3 yrs(Incl. DWI/DUI5 yrs/3 yrs MT)

Number of:

of 5 pages PUP 276 (01/11)

Definitions and Question Details

Defintions:

"You", "Your" and "I" means the applicant.

"Member of your household" means your spouse and any person related to you by blood, marriage or adoption who either lives withyou or is away at school and anyone who lives with you and is in your or a relative’s care or custody. "Driver" means you and members of your household who operates a vehicle owned, leased, rented, or regularly operated by you ora member of your household at least 50% or more of that vehicle's use.

"Incident(s)" includes any moving violation, at-fault accident and/or traffic arrest, citation or conviction.

"At-Fault Accident" includes any single or multi-car accident chargeable under a primary auto policy, any accident resulting in anypayment for bodily injury or property damage, any single car accident resulting in payment to an insured (unless caused by an animal),and/or any accident resulting in a citation to you or a member of your household with or without a conviction or final adjudication.

"Antique, classic or collector vehicles" includes private passenger vehicles more than 20 years old, licensed for road use, driven lessthan 2,500 miles annually, owned for limited pleasure use, car shows and club events and insured under a Collectors AutomobilePolicy.

Question Details:

All Questions: You and all members of your household should be considered when answering any question on this application.

Question 1: Include company vehicles provided for your use, or for use by a member of your household. All vehicles licensed forroad use need to be counted regardless of individual insurance. Full Timers should count their RV as a vehicle and not a residence.

Question 2 & 21: Primary residences must have liability coverage under a policy containing Comprehensive Personal Liability(including Homeowners and Farmowners). Seasonal, secondary or rental properties may have liability coverage under aComprehensive Personal Liability or Premises Liability Policy. Do not include residential properties that are covered under aCommercial General Liability Policy or other non-personal Premises Liability Policy as they are excluded from coverage.

Question 6: In KS and MA, count only those drivers with six years or less driving experience. Driving with a permit is notconsidered driving experience and should not be included with the six years as driving experience.

Question 8: In FL, count only moving violations with one or more points assessed to the driver’s license.

Question 11: RLI provides worldwide coverage, provided suit on the merits is brought in the U.S. (including its territories andpossessions), Puerto Rico or Canada.

PUP Helpful Hints:

• PUP Special exposure charges are added to either the Preferred, Standard or Standard II premium. For further explanation, referto your state rate sheet.

• Drivers under the age of 20 may not have any incidents.

• Drivers age 20 to 21 or age 80 or over may not have any alcohol related incidents. These drivers may have only one incident.

• The total number of properties allowed is 10. The maximum acceptable number of residential properties rented to others that arenot occupied in whole or in part at any time by you or any member of your household is 5. The maximum number of residentialproperties owned or rented by you or any member of your household located outside the U.S. (including its territories andpossessions), Puerto Rico and Canada is 5.

• The exposure charge for 641 to 1280 acres is a flat charge. It is not a per acre charge.

• Required underlying liability limits for Automobile, Uninsured/Underinsured Motorist (UM/UIM), Property, and Watercraft arelisted on the application. Carefully review these limits and make certain that you and all members of your household arecarrying the proper underlying amount of coverage.

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This is another reminder to the insured that they must maintain all of the agreed upon underlying limits to be eligible for coverage. UM/UIM has now been added to this paragraph and only applies if the insured accepts this coverage.

(The named insured may be a maximim of two individuals, provided both individuals reside in the same household. This policy cannot be issued in the name of an estate, trust or LLC.)

* If there are drivers age 70 or over AND an answer to questions 8 or 9 falls under the Standard II (N/A in HI) or the PUP Specialcolumn, the risk is not eligible.

** $1 Million is the ONLY available limit for PUP Special.

7. How many drivers are age 70 or over? Note: This response is not considered whendetermining the rating tier for applicants in Maine. (Include any member of yourhousehold with a driver's license).

8. How many moving violations have all drivers had within the last 3 years? (IncludeDWI/DUI incidents within the last 5 years or 3 years in MT.) (See question 27).

9. How many at-fault accidents have all drivers in your household had in the last 3years? (See question 27).

Page 1 of 5 pages PUP 276NUM (01/11)

Name

PrimaryResidence Address

City State Zip

Mailing Address (if different from Primary Residence Address)

Address

City State Zip Phone ( ) -E-mail:

QUESTIONS1-9

Carefully read questions 1 through 9 and respond by circling thecorrect number. If any question is unanswered or answered in the"Not Eligible" column, the risk is not eligible. Preferred Standard

*StandardII

NotEligible

1. How many motorized vehicles licensed for road use (i.e., motor homes,motorcycles, cars, etc.) are owned, leased, rented, or regularly operated by you orany member of your household? (Do not count antique, classic or collectiblevehicles. See question 10.)

4. How many jet skis, waverunners or other personal watercraft are owned or regularlyoperated by you or any member of your household?

6. How many drivers are under the age of 22? (Include any member of your house-hold with a learner's permit or driver's license and see the definition of "driver" onpage 5.)

PERSONAL UMBRELLA LIABILITY INSURANCE APPLICATION

ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATIONMUST BE INITIALED BY THE APPLICANT.

5. What is the total number of drivers? (Include drivers with a learner's permit.)

2. How many residential properties are owned or rented by you or any member of yourhousehold? 1-4 family units are eligible and should be counted as one property. Donot include residential properties that are covered under a Commercial GeneralLiability Policy or other non-personal Premises Liability Policy since they areexcluded from coverage.

3. How many watercraft, between 14 and 45 ft. and with a maximum speed of 50 mph,are owned or regularly operated by you or any member of your household?Watercraft exceeding these limitations are excluded from coverage. (Do not countcanoes, jet skis, waverunners or other personal watercraft. See question 4.)


**PUPSpecial

($1 Mill Max)

See page 5 for definitions and question details.

Excess UM/UIM coverage is not available for purchase under this application.

PUP 2076NUM (01/11)

____________________________

0 1 2 3 4 5 6 7 8 9 10 11 or more

0 1 2 3 4 5 6 7 8 9 10 11 or more

0 1 2 3 4 or more

0 1 2 3 4 or more

0 1 2 3 4 5 6 7 8 9 or more

0 1 2 3 4 5 or more

0 1 2 3 4 5 or more

0 1 2 3 4 5 6 7 or more

0 1 2 3 4 or more


Requested Effective Date Premium

$5 Million $3 Million $2 Million $1 Million

Coverage Limit Desired:

Applicant's Brokering Agent Number

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Application version to be used ONLY in states where Excess UM/UIM is not yet available. PUP276 (09/09) will also be acceptable for these states.

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New wording to show that this app is not acceptable for UM/UIM states.

17. Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years? YES NO


19. Have you or any member of your household had any personal liability or personal auto bodily injury liability claims forwhich payment by your insurance company exceeded $25,000 in the last 5 years?

16. Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving (with 4 points inFL), negligent driving and/or had a driver's license suspended (for reasons other than driving under the influence of alcoholor drugs), revoked or refused in the last 5 years or 3 years in MT? (Careless or negligent driving N/A in SC)

18. Do you or any member of your household have an occupation of a professional entertainer or athlete, media personality,or an appointed or elected federal or state political figure? (N/A for political figures in FL, OR and TX.)

YES NO

YES NO

YES NO

QUESTIONS10 - 15

Print the response clearly on the line provided. If the question is unanswered or the response is greater than the maximum numberindicated, the risk is not eligible. PUP Special charge(s) apply if any answer to questions 11 through 15 is greater than 0 (or greaterthan 640 for question 12).

20. Does any other member of your household or other person residing in your household have a Personal Umbrella policywith RLI Insurance Company other than this policy? YES NO

21. Do you or any member of your household own (including partial ownership) 6 or more residential properties rented toothers that are not occupied in whole or in part at any time by you or any member of your household? 1-4 family units areeligible and should be counted as one property. YES NO


10. How many antique, classic and/or collectible vehicles are owned by you or any member of your household? (Max. of 25)

11. How many residential properties owned or rented by you or any member of your household are located outside of the U.S. (includingits territories and possessions), Puerto Rico or Canada? (Max. of 5)

12. How many acres of timberland and/or land that is farmed, for which the liability coverage is provided by a Homeowners, Farmowners orFarm Comprehensive Personal Liability Policy do you or any member of your household own or lease (including partial ownership)?(Max. of 1280)

13. How many drivers have been licensed to drive in the U.S. less than one year, currently have a learner's permit, and/or have a non-U.S.driver's license? A year or more with a learner's permit does not qualify as a year with a driver's license. (Max. of 8)

14. How many driving incidents have all drivers ages 20-21 and/or age 80 or over had within the last 3 years? (Max. 1 per driver)

QUESTIONS16 - 24 Read and respond by checking "Yes" or "No". If any question is unanswered or checked "Yes", the risk is not eligible.

15. How many arrests, citations or license suspensions for driving under the influence of alcohol/drugs, driving while intoxicated and/or anyother alcohol/drug related incidents have all drivers had in the last 5 years or 3 years in MT? (Max. 1 per household for drivers betweenages 22 and 79; 0 per household for drivers under ages 22 and 80 or over.)

22. Has any one driver had more than 3 moving violations in the last 3 years? (Include DWI/DUI incidents within the last 5years or 3 years in MT.) YES NO

23. Has any driver under the age of 20 had a driving incident within the last 3 years? YES NO24. Has any one driver ages 20-21 or age 80 or over had more than one driving incident within the past 3 years? YES NO

QUESTION25

Carefully read Question 25 and respond by checking "Yes" or "No". If left unanswered or checked "No," therisk is not eligible.

25. Do you and ALL members of your household agree to maintain the MINIMUM REQUIRED LIMITS OF LIABILITY coverageoutlined below as a condition of coverage? For those limits that currently do not apply to you or any member of your household,you must agree to maintain those limits only if they become applicable to you or any member of your household during the policyperiod as a condition of your coverage.

YES NO

IndicateResponse

Below


PERSONAL LIABILITY



PERSONAL LIABILITY


FARMOWNERS OR FARMCOMPREHENSIVE PERSONAL LIABILITY

(Required only if you or any member of yourhousehold own a farm which is not covered




(Required only if you or a member of yourhousehold own or acquire an unlicensed recreational

vehicle during the policy period that is not covered by your homeowners or personal liability

policy for the following limits of liability.)


-OR- $100,000/$300,000/$25,000




policy period that is not covered by yourhomeowners or personal liability policy for the

following limits of liability.)


$250,000/$500,000/$100,000-OR-

$300,000/$300,000/$100,000






QUESTION26

Carefully read Question 26 and respond by selecting one limit (A, B, or C) in the box provided. You MUST agree tomaintain one of the three limits outlined in question 26, regardless of whether you currently own, lease, rent or operatea vehicle. If left unanswered, the risk is not eligible.

26. Which of the following MINIMUM REQUIRED LIMITS OF AUTOMOBILE LIABILITY do you and all members of yourhousehold agree to maintain as a condition of coverage for all licensed vehicles, that are owned, leased, rented, operated oracquired during the policy period? You agree that this condition applies equally to personal use of a vehicle covered under aCommercial Automobile Liability Policy.

OptionA, B, or C

Selected Below




Limit B






Limit C





Excess UM/UIM is not availableif you maintain Limit C.


Please be sure to sign application on page 4.

Limits B and C are available options ONLY if all drivers in the household are age 22 and over.Limit C is NOT available if there are any drivers age 70 or over in the household; and/or if anyresponse makes the risk Standard II (N/A in HI); and/or if any response makes the risk PUPSpecial.


-OR-If the answer to question 15 is >0

-OR-In KS and MA, if there are drivers with six

years or less driving experience in thehousehold.

Limit A



QUESTION27

Complete the following for all members of your household age 14 and older. Also include on this list any other person whooperates a vehicle owned, leased, rented or regularly operated by you or a member of your household at least 50% or more of thatvehicle's use.

Date of Birth

Licensed or Permit?

Y/N

Drivers Licenseor


ApplicantDWI/DUI

Y/N

At-FaultAccidents

(3 yrs)

Violations 3 yrs(Incl. DWI/DUI5 yrs/3 yrs MT)

Number of:

A B C

of 5 pages PUP 276NUM (01/11)

APPLICANT STATEMENT: The information given on this application is true and complete to the best of my knowledge. I understand that anyomission or misstatement of fact in the information given voids the policy. I agree that I will acquire and maintain Minimum Required Limits ofLiability for all additional exposures (drivers, houses, vehicles, watercraft, etc.) if they become applicable during the policy period. The insured'sBrokering Agent shall not have the right to make, alter, modify, or discharge any contract or policy issued on the basis of this Application. Iunderstand that the application and prepayment of premium must be accepted by RLI Insurance Company.

IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: I understand that as a part of the underwritingprocedure, a consumer report may be obtained or an investigative consumer report may be prepared. Such reports may include information regardingmy driving record, credit history, general reputation, personal characteristics and mode of living. I hereby consent to the preparation of such reportsand the disclosure of such reports to RLI Insurance Company and the producer of record. I understand that these reports will be handled in thestrictest confidence, and that information as to the nature and the scope of these reports will be provided to me upon request.

DATE APPLICANT'S ORIGINAL SIGNATURE:

APPLICANT'S BROKERING AGENT'S SIGNATURE:

APPLICANT'S BROKERING AGENCY'S NAME:

APPLICANT'S BROKERING AGENCY'S ADDRESS:

APPLICANT'S BROKERING AGENT'S LICENSE ID #:

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerning anymaterial fact thereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil penalties.

ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATION MUST BE INITIALED BY THE APPLICANT.THE SAME VERSION DATE MUST APPEAR ON ALL 4 PAGES OF THE APPLICATION.

I UNDERSTAND THIS APPLICATION IS NOT A BINDER and NO INSURANCE WILL BE IN EFFECT UNTIL RLIINSURANCE COMPANY ISSUES A POLICY. THE APPLICATION WILL NOT BE ACCEPTED WITHOUT

APPLICANT'S ORIGINAL SIGNATURE.A Power of Attorney letter must accompany the application, where applicable.

A PREMIUM CHECK MUST ACCOMPANY THE APPLICATION TO COMPLETE PROCESSING.

(FL Requirement: This application is in compliance with Section 626.752, Florida Statutes. A copy has beenfurnished to the applicant and coverage is Not Bound.)


ExcessUM/UIM

Carefully read the information below on Excess Uninsured/Underinsured coverage offered by RLI. If you wish to purchase ExcessUM/UIM coverage, an alternative application is required in states where RLI offers Excess UM/UIM.

EXCESS UNINSURED/UNDERINSURED MOTORIST (UM/UIM) COVERAGE: Excess UM/UIM coverage is offered by RLIfor an additional premium in states that have approved our Excess UM/UIM rates and coverage form. Required Basic UM/UIM policy limits mustbe equal to the liability limits for the Required Basic Automobile Liability Policy. For residents of FL, IN, LA, NH, VT, WI or WV you mustsubmit the referenced state mandated form.

FL and WV: If you elect to purchase this coverage, you are required to accept this coverage in writing and pay the additional premium. If youaccept UM/UIM coverage you must complete and return form PUP257B in FL or forms PUP547A and PUP547B in WV.

VT: Matching limits of UM/UIM are available for an additional premium. If you elect to reduce the UM/UIM limits to the statutory minimum of$100,000, you must complete and return form PUP257D. Receipt of the applicable form by the company will result in a reduction in the premium.

WI: Limits of $100,000/$300,000 of UM, UIM or both UM/UIM are available for an additional premium. If you reject UM, UIM or UM/UIMcoverage, you must complete and return form PUP248A. Receipt of the applicable form by the company will result in a reduction in the premium.

IN, LA and NH: If you elect to reject UM/UIM coverage you must complete and return form PUP257A in IN and NH and PUP517 in LA.Receipt of the applicable form by the company will result in a reduction in the premium.

All Other States: Excess UM/UIM coverage is offered by RLI in states where the Department of Insurance has approved our rates and coverageform. As Excess UM/UIM coverage becomes available, it will be published at www.rlipersonalumbrella.com/excessum. An alternative applicationis required in states where RLI offers Excess UM/UIM.

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An updated list of approved Excess UM/UIM states will be available on our website.

of 5 pages PUP 276NUM (01/11)


Defintions:

"You", "Your" and "I" means the applicant.

"Member of your household" means your spouse and any person related to you by blood, marriage or adoption who either lives withyou or is away at school and anyone who lives with you and is in your or a relative’s care or custody. "Driver" means you and members of your household who operates a vehicle owned, leased, rented, or regularly operated by you ora member of your household at least 50% or more of that vehicle's use.


"At-Fault Accident" includes any single or multi-car accident chargeable under a primary auto policy, any accident resulting in anypayment for bodily injury or property damage, any single car accident resulting in payment to an insured (unless caused by an animal),and/or any accident resulting in a citation to you or a member of your household with or without a conviction or final adjudication.

"Antique, classic or collector vehicles" includes private passenger vehicles more than 20 years old, licensed for road use, driven lessthan 2,500 miles annually, owned for limited pleasure use, car shows and club events and insured under a Collectors AutomobilePolicy.

Question Details:

All Questions: You and all members of your household should be considered when answering any question on this application.

Question 1: Include company vehicles provided for your use, or for use by a member of your household. All vehicles licensed forroad use need to be counted regardless of individual insurance. Full Timers should count their RV as a vehicle and not a residence.

Question 2 & 21: Primary residences must have liability coverage under a policy containing Comprehensive Personal Liability(including Homeowners and Farmowners). Seasonal, secondary or rental properties may have liability coverage under aComprehensive Personal Liability or Premises Liability Policy. Do not include residential properties that are covered under aCommercial General Liability Policy or other non-personal Premises Liability Policy as they are excluded from coverage.

Question 6: In KS and MA, count only those drivers with six years or less driving experience. Driving with a permit is notconsidered driving experience and should not be included with the six years as driving experience.

Question 8: In FL, count only moving violations with one or more points assessed to the driver’s license.

Question 11: RLI provides worldwide coverage, provided suit on the merits is brought in the U.S. (including its territories andpossessions), Puerto Rico or Canada.

PUP Helpful Hints:

• PUP Special exposure charges are added to either the Preferred, Standard or Standard II premium. For further explanation, referto your state rate sheet.

• Drivers under the age of 20 may not have any incidents.

• Drivers age 20 to 21 or age 80 or over may not have any alcohol related incidents. These drivers may have only one incident.

• The total number of properties allowed is 10. The maximum acceptable number of residential properties rented to others that arenot occupied in whole or in part at any time by you or any member of your household is 5. The maximum number of residentialproperties owned or rented by you or any member of your household located outside the U.S. (including its territories andpossessions), Puerto Rico and Canada is 5.

• The exposure charge for 641 to 1280 acres is a flat charge. It is not a per acre charge.

• Required underlying liability limits for Automobile, Uninsured/Underinsured Motorist (UM/UIM), Property, and Watercraft arelisted on the application. Carefully review these limits and make certain that you and all members of your household arecarrying the proper underlying amount of coverage.

PERSONAL UMBRELLA LIABILITY POLICY

Policy Number

Named Insured & Mailing Address Agent

Policy Period - 12:01 A.M. standard time at the addressof the Named Insured as stated herein. From To

Minimum Limit of CoverageBasic Policy

A. Automobile Liability Bodily Injury$ each occurrence

Property Damage $ each occurrence

(continued on page 2)

Page 1 of

Limit of Coverage $ each occurrence

$ each person

Policy Premium

Primary Residence Address (if different than above)

Forms included at issue will appear on Page 2 of this Declaration.

each occurrence

PUP 301 (04/10)

This Declarations page with "Policy Provisions" completes this policy.

$Self-Insured Retention: $


A stock insurance company, herein called the Company

DECLARATIONS

2PUP 301 (04/10)

Excess Uninsured/Underinsured MotoristsLimit of Coverage $ each accident

REQUIRED BASIC POLICIESIt is agreed by you that you and any Relative will be covered by an Automobile liability policy for any Automobile you operate oryour Relative operates for at least the minimum limits listed below. It is also agreed by you that you and any Relative will becovered by a personal liability policy for at least the minimum limits listed below. If you or your Relatives are not covered underyour policies for at least the minimum limits listed below, they must be covered under another Automobile liability policy andanother personal liability policy for at least the minimum limits below. If you or your Relatives own a Farm, Seasonal/Secondary/Rental Properties, Recreational Vehicles or Watercraft, you or your Relatives, as the case may be, agree to carry the appropriatepolicy (or endorsements) listed below covering both you and your Relatives for at least the minimum limits listed below.

orBodily Injury and Property DamageCombined Single Limit $ each occurrence

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This is an example of a declaration page when Excess UM/UIM is included. The correspond info will show in this box as well as Box B at the top of page 2.

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Basic Policy Minimum Limit of Coverage

D. Recreational Vehicle Liability Bodily Injury$ 300,000 each occurrence

Property Damage $ 25,000 each occurrence

orBodily Injury and Property DamageCombined Single Limit $ 100,000 each occurrence

E. Watercraft Liability(including, but not limited to, Bodily Injurypersonal watercraft) $ 300,000 each occurrence


orBodily Injury

$ 500,000 each occurrenceProperty Damage $ 100,000 each occurrence


C. Personal Liability1. PRIMARY RESIDENCE

Homeowners or Personal Liability Bodily Injury and Property DamageCombined Single Limit $ 300,000 each occurrence

2. SEASONAL, SECONDARY OR RENTAL PROPERTIESComprehensive Personal Liability or Premises Liability

Bodily Injury and Property DamageCombined Single Limit $ 300,000 each occurrence

3. FARMFarmowners or Comprehensive Personal Liability Bodily Injury and Property Damage

Combined Single Limit $ 300,000 each occurrence

$ 100,000 each person



$ $ $

each occurrenceeach occurrence

Bodily Injury each person

Property Damage

B. Uninsured/Underinsured Motorists

Page 2 of 2PUP 301 (04/10)

orBodily Injury and Property DamageCombined Single Limit each occurrence $

Forms included at issue:


Policy Number

Named Insured & Mailing Address Agent

Policy Period - 12:01 A.M. standard time at the addressof the Named Insured as stated herein. From To

Minimum Limit of CoverageBasic Policy

A. Automobile Liability Bodily Injury$ each occurrence

Property Damage $ each occurrence

(continued on page 2)

Page 1 of

Limit of Coverage $ each occurrence

$ each person

Policy Premium

Primary Residence Address (if different than above)

Forms included at issue will appear on Page 2 of this Declaration.

each occurrence

PUP 301 (04/10)

This Declarations page with "Policy Provisions" completes this policy.

$Self-Insured Retention: $



DECLARATIONS

2PUP 301 (04/10)

Excess Uninsured/Underinsured MotoristsLimit of Coverage $ each accident Coverage Rejected

REQUIRED BASIC POLICIESIt is agreed by you that you and any Relative will be covered by an Automobile liability policy for any Automobile you operate oryour Relative operates for at least the minimum limits listed below. It is also agreed by you that you and any Relative will becovered by a personal liability policy for at least the minimum limits listed below. If you or your Relatives are not covered underyour policies for at least the minimum limits listed below, they must be covered under another Automobile liability policy andanother personal liability policy for at least the minimum limits below. If you or your Relatives own a Farm, Seasonal/Secondary/Rental Properties, Recreational Vehicles or Watercraft, you or your Relatives, as the case may be, agree to carry the appropriatepolicy (or endorsements) listed below covering both you and your Relatives for at least the minimum limits listed below.

orBodily Injury and Property DamageCombined Single Limit $ each occurrence

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This will show if the insured rejects UM/UIM coverage.

Basic Policy Minimum Limit of Coverage

D. Recreational Vehicle Liability Bodily Injury$ 300,000 each occurrence



E. Watercraft Liability(including, but not limited to, Bodily Injurypersonal watercraft) $ 300,000 each occurrence


orBodily Injury

$ 500,000 each occurrenceProperty Damage $ 100,000 each occurrence


C. Personal Liability1. PRIMARY RESIDENCE

Homeowners or Personal Liability Bodily Injury and Property DamageCombined Single Limit $ 300,000 each occurrence

2. SEASONAL, SECONDARY OR RENTAL PROPERTIESComprehensive Personal Liability or Premises Liability

Bodily Injury and Property DamageCombined Single Limit $ 300,000 each occurrence

3. FARMFarmowners or Comprehensive Personal Liability Bodily Injury and Property Damage

Combined Single Limit $ 300,000 each occurrence




$ $ $

each occurrenceeach occurrence

Bodily Injury each person

Property Damage

B. Uninsured/Underinsured Motorists

Page 2 of

Not Applicable.

Excess UM/UIM was rejected by insured.

2PUP 301 (04/10)

orBodily Injury and Property DamageCombined Single Limit each occurrence $

Forms included at issue:

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If the insured rejects UM/UIM coverage, this statement will be attached.

RENEWAL BUSINESS

PURCHASE/REJECTION OFEXCESS UNINSURED MOTORISTS/UNDERINSURED MOTORISTS COVERAGE

Please return this form with your completed renewal application.

This is NOT a bill! Do not pay this amount.A renewal bill will follow upon receipt and review of this information.

IMPORTANT!

In order for RLI to successfully process your renewal application, this notice must be completed as follows:1. Indicate whether you wish to reject or purchase Excess UM/UIM Coverage.2. Sign and date this form.3. Return this form with your completed renewal application.4. Failure to return this form will result in your policy renewing with the same Excess UM/UIM coverage

election as your current policy.Thank You.

I understand that if I purchase this coverage, I will be required to maintain the same limits of liability for Uninsured Motorists/Underinsured Motorists Coverage as I am required to carry for my Automobile Liability Coverage under my primaryautomobile policy(ies).

This election will remain in effect for this policy and any renewal of this policy unless RLI Insurance Company is notified inwriting.

________________________________________ ___________________________________SIGNATURE OF NAMED INSURED DATE

I REJECT THIS COVERAGE AND AGREE THAT EXCESS UNINSURED MOTORISTS/UNDERINSUREDMOTORISTS COVERAGE WILL NOT BE INCLUDED IN MY POLICY.

I WANT TO PURCHASE THIS COVERAGE AND AGREE THAT EXCESS UNINSURED MOTORISTS/UNDERINSURED MOTORISTS COVERAGE WITH A LIMIT OF $1 MILLION PER ACCIDENT WILL BEINCLUDED IN MY POLICY. THE ADDITIONAL CHARGE ESTIMATED BELOW WILL BE INCLUDED IN MYRENEWAL BILL.

PUP 261 (01/11)

Excess Uninsured Motorists/Underinsured Motorists (UM/UIM) coverage at a limit of $1 million per accident is now offered inyour state for an additional premium. Required Basic UM/UIM policy limits must be equal to the liability limits for theRequired Basic Automobile Liability Policy. If you purchase this coverage, an additional charge as indicated below will beincluded in your renewal bill. Please indicate below if you wish to purchase or reject this coverage.

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx



The charge for this coverage, determined from the information we currently have in your file, is$ , based on a $1 million Excess Uninsured Motorists/Underinsured Motorists Coverage limit,for the policy period of to .

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This estimate is based on the number of drivers in the household during the previous term. The amount may fluctuate if the number of drivers changes.

All sections outlined in Red require your response

Questions1-14

On File

Personal Umbrella Liability InsuranceRenewal Application

9025 N. Lindbergh Dr. Peoria, IL 61615Name & Mailing Address: Return form to RLI by:

Policy Expiration Date:Policy Number:

Billing Address:

Primary Residence Address:


PLEASE REVIEW AND COMPLETE QUESTIONS 22-23 AND SIGN THE APPLICATION ON THE REVERSE SIDE

Our records show the following information on your file. Carefully review the information for accuracy. If any of theinformation is incorrect, please print the correct answer in the boxes provided. See Page 3 for Definitions andQuestion Details.

1. How many motorized vehicles licensed for road use (i.e., motorhomes, motorcycles, cars, etc.) are owned, leased, rented, or regularlyoperated by you or any member of your household?

Questions15-21

Carefully read questions 15 through 21 and check the box for each question that has a "Yes" response. All members of your household should be considered when answering these questions. See Page 3 forDefinitions and Question Details.

Check If"Yes"

3. How many watercraft, other than canoes, jet skis, waverunners or other personal watercraft, are owned or regularly operated by you orany member of your household?

4. How many jet skis, waverunners or other personal watercraft are owned or regularly operated by you or any member of yourhousehold?

5. How many drivers are in your household? (Include any members of your household with a learner’s permit or a valid driver’s license)

6. How many drivers are under the age of 22? (Include any members of your household with a learner’s permit or a valid driver’slicense)

7. How many drivers are age 70 or over? (Include any members of your household with a valid driver's license)

8. How many moving violations have all drivers had within the last 3 years? Include DWI/DUI incidents within the last 5 years or 3 yearsin Montana. (Update chart on page 2)

9. How many at-fault accidents have all drivers in your household had in the last 3 years? (Update chart on page 2)

10. How many antique, classic and/or collectible vehicles are owned by you or any member of your household?

2. How many residential properties are owned or rented by you or any member of your household? 1-4 family units are eligible andshould be counted as one property.

15. Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving (with 4 points in FL) negligentdriving and/or had a driver's license suspended (for reasons other than driving under the influence of alcohol or drugs), revoked orrefused in the last 5 years or 3 years in Montana? (Careless or negligent driving N/A in SC)

16. Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years?

17. Do you or any member of your household have an occupation of a professional entertainer or athlete, media personality, or anappointed or elected federal or state political figure? (N/A for political figures in FL, OR & TX)

E-mail Address:

12. How many acres of timberland and/or land that is farmed, for which the liability coverage is provided by a Homeowners, Farmowners orFarm Comprehensive Personal Liability Policy do you or any member of your household own or lease? (Including partial ownership)

14. How many arrests, citations or license suspensions for driving under the influence of alcohol/drugs and/or driving while intoxicatedand/or any other alcohol/drug related incidents have all drivers had in the last 5 years or 3 years in Montana?

11. How many residential properties owned or rented by you or any member of your household are located outside Canada, Puerto Ricoor the U.S. (including U.S. territories and possessions)?

UpdateBelow

18. Do you or any member of your household own (including partial ownership) 6 or more residential properties rented to others that arenot occupied in whole or in part at any time by you or any member of your household? 1-4 family units are eligible and should becounted as one property.

13. How many driving incidents have all drivers ages 20-21 and/or age 80 and over had within the last 3 years?

19. Has any one driver had more than 3 moving violations within the last 3 years? (Include DWI/DUI incidents within the last 5 years or 3years in Montana.)

20. Has any driver under the age of 20 had a driving incident within the last 3 years?

21. Has any one driver ages 20-21 or age 80 or over had more than one driving incident within the past 3 years?

PUP 207 (07/08)

_________________________________


The named insured may be a maximum of two individuals, provided both individuals reside in the same household. This policy cannotbe issued in the name of an estate, trust or LLC. This form must be completed, signed and dated by a named insured.

of 3 pages PUP 207 (09/10)

23. Carefully read the following statement in italics: that you and all member of yourhousehold agree to maintain these same MINIMUM REQUIRED LIMITS OF LIABILITY coverage outlined in the chart onPage 3 as a condition of your coverage for all licensed vehicles that are owned, leased, rented, operated or acquired atany time during the policy period. You agree that this condition applies equally to personal use of a vehicle under aCommercial Automobile Liability Policy. If you have a driver under the age of 22 in the household, refer to Limit A in thechart on Page 3 for the required limit information. NOTE: The response you previously provided regarding yourAutomobile Liability coverage is in the box to the right.

If you are unsure what underlying coverage limits you are carrying, or are required to carry, we suggest contacting your local agent.

IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: I understand that as part of the underwriting procedure, aconsumer report may be obtained or an investigative consumer report may be prepared. Such reports may include information regardingmy driving record, credit history, general reputation, personal characteristics and mode of living. I hereby consent to the preparation ofsuch reports and the disclosure of such reports to RLI Insurance Company and the producer of record. I understand that these reports willbe handled in the strictest confidence, and that information as to the nature and scope of these reports will be provided to me uponrequest.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerningany material fact thereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civilpenalties.

APPLICANT STATEMENT: Read Carefully Before Signing. The information given on this form is true and complete to the best of myknowledge. I understand that any omission or misstatement of fact in the information given voids the policy. I further understand that, for anadditional premium, Uninsured or Underinsured Motorist (UM/UIM) coverage is offered in Florida, Indiana, Louisiana, New Hampshire,Vermont, West Virginia and Wisconsin and I must elect the coverage in writing. I understand that UM/UIM coverage is not offered by thecompany under this renewal application form in any other state. I agree that Minimum Primary Limits or Basic Policies outlined on page 3are required and will be maintained during the policy period and that no insurance will be in effect until RLI issues a Policy. I agree that Iwill acquire and maintain Minimum Required Limits of Liability for all additional exposures (drivers, houses, vehicles, watercraft, etc.) if theybecome applicable during the Policy period. I should contact my local insurance agent to confirm adequate basic limits for all exposures

Informationon File

UpdateBelow

APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT'S ORIGINAL SIGNATURE.

If a Power of Attorney is used, a copy of the Power of Attorney letter must accompany the Application.

Applicant's Daytime Phone #_____________________OriginalSignature____________________________________________________ Date _______________________________

22. Carefully read the following statement in italics. that you and ALL members of your household agree tomaintain the MINIMUM REQUIRED LIMITS OF LIABILITY coverage outlined in the chart on Page 3 as a condition of your coverage. For thoselimits that currently do not apply to you or any member of your household, you agree to maintain those limits if they become applicable to youor any member of your household during the policy period as a condition of your coverage.

Your signature below confirms


Questions22-23 Carefully read questions 22 and 23 and refer to the charts on Page 3.

Please refer to Page 3 for Definitions and Question Details.


Question24

Complete the following for all members of your household age 14 and older. Also include on this list any other peoplewho operate a vehicle owned, leased, rented or regularly operated by you or a member of your household at least 50%or more of that vehicle's use.

Date of Birth

Licensed?Permit?

Y/N

Drivers Licenseor


Applicant

DWI/DUIY/N

At-FaultAccidents

(3 yrs)

Violations 3yrs(Incl. DWI/DUI

5 yrs/3 yrs in MT)

Number of:

xx xxxxxx

xx xxxxxx

of 3 pages PUP 207 (09/10)





-OR- If the answer to Question 14 is >0

-OR-In KS and MA, if there are drivers with 6 yearsor less driving experience in the household.




Excess UM/UIM is not available if you maintain Limit C.

Question 23:

Limit A

Definitions

"You," "Your," and "I" means the applicant.

"Member of your household" means your spouse and any person related to you by blood, marriage or adoption who either lives with you or is away atschool and anyone who lives with you and is in your or a relative's care or custody.

"Driver" means "you" and "members of your household" who operate motor vehicles licensed for road use, plus any other person who operates avehicle owned, leased, rented, or regularly operated by you or a member of your household at least 50% or more of that vehicle's use.


"At-Fault Accident" includes any single or multi-car accident chargeable under a primary auto policy, any accident resulting in any payment for bodily injuryor property damage, any single car accident resulting in a payment to an insured (unless caused by an animal), and/or any accident resulting in a citation toyou or a member of your household with or without a conviction or final adjudication.

"Antique, classic or collectible vehicle" includes private passenger vehicles more than 20 years old, licensed for road use, driven less than 2,500 milesannually, owned for limited pleasure use, car shows and club events and insured under a Collectors Automobile Policy.

"Personal watercraft" includes small but powerful motorized watercraft sold under brand names such as Jet Ski and WaveRunner usually used by 1-3people and under 14 feet in length.

Question Details

Question 1: Include company vehicles provided for your use or for use by a member of your household. All vehicles licensed for road use need to becounted regardless of individual insurance. Full Timers should count their RV as a vehicle and not a residence. Do not count antique, classic or collectiblevehicles covered under a Collectors Automobile Policy. See Question 10.

Question 2: Primary residences must have liability coverage under a policy containing Comprehensive Personal Liability (including Homeowners andFarmowners). Seasonal, secondary or rental properties may have liability coverage under a Comprehensive Personal Liability or Premises Liability Policy.Do not include residential properties that are covered under a Commercial General Liability Policy or other non-personal Premises Liability Policysince they are excluded from coverage.

Question 3: Count only watercraft between 14 and 45 ft. and with a maximum speed of 50 mph. Watercraft exceeding these limitations are excludedfrom coverage.

Question 6: In KS and MA, count only those drivers with six years or less driving experience. Driving with a permit is not considered driving experience andshould not be included within the six years as driving experience.

Question 8: In Florida, count only moving violations with 1 or more points assessed to the drivers license.

Question 22:



PERSONAL LIABILITY


SEASONAL, SECONDARY OR RENTALPROPERTIES REQUIRE PREMISES LIABILITY

OR COMPREHENSIVE PERSONAL LIABILITY


FARMOWNERS OR FARM COMPREHENSIVEPERSONAL LIABILITY

(Required only if you or any member of yourhousehold own a farm that is not covered




(Required only if you or a member of yourhousehold own or acquire an unlicensed

recreational vehicle during the policy period that is not covered by your homeowners

or personal liability policy for the following limits of liability.)


-OR- $100,000/$300,000/$25,000




policy period that is not covered by yourhomeowners or personal liability policy for

the following limits of liability.)


$250,000/$500,000/$100,000-OR-

$300,000/$300,000/$100,000





Limits B and C are available options ONLY if all drivers in the household are age 22 and over.Limit C is NOT available if there are any drivers age 70 or over in the household.





$300,000 Combined Single Limit per occurrence($325,000 in TX)

Limit B Limit C

Dear Policyholder,

It is time to update your file so that we can renew your RLI personal umbrella policy.

Please note that your agent does not receive a copy of this information. It is your responsibility to complete this formand return it to RLI to renew your coverage. However, your Brokering Agent can provide guidance on coverages orassistance with completing the form. Your Brokering Agent’s name and phone number are highlighted on theattached application. If you do not return this application, we will not have the information needed to determine yourrenewal coverages and premium, and your policy will not be renewed.

The form is quick and easy to complete. Just follow these 8 simple steps:

1. Check your name and address on the application. Write any changes next to this information. Have you moved?No problem! RLI offers personal umbrella protection in all 50 states and DC.

2. For your convenience, we have pre-filled your prior answers, when available, to questions 1-14. Please reviewthese answers and correct them, as necessary, with updated information.

3. Carefully read questions 15-21 and answer “YES” if the question applies to you or any member of yourhousehold.

4. Please carefully read questions 22 and 23 on the back side of the page. When you sign the renewal application,you agree to maintain the required minimum underlying limits specified on page 3 of this application. If yourauto limits have changed, please note this on question 23.

5. Complete and/or verify ALL INFORMATION in the chart for question 24 for any member of your householdage 14 and over, whether they are licensed to drive or not. There should be no blanks in the chart for anyindividual listed. If the question does not apply to that individual, insert a “0”.

6. Sign and date the application. If this form is signed by a power of attorney or other representative of the insured,please attach the appropriate legal paperwork.

7. Return the signed application to RLI in the envelope provided.

8. Note this is a 3 page form. Bolded words in the questions are defined terms in your policy and Page 3 containstheir definition and other helpful information to assist you when answering the questions.

Why do we need this information? Changes in your life and in your home and auto insurance coverages may impactthe premiums we charge (many times they go down!). Once we receive this information, you will receive an invoiceto continue coverage or, in some cases, an explanation for why we may no longer be able to offer coverage.

Thank you for putting your trust in RLI. We look forward to the opportunity to protect you in the future.

QRN 12 (03/10)

IMPORTANT NOTICE ABOUT RENEWING YOUR PERSONAL UMBRELLA POLICY

9025 N. Lindbergh Dr. | Peoria, IL 61615-1431


Tammy CraigPolicyholder Services


All sections outlined in Red require your response

Questions1-14

On File

Personal Umbrella Liability InsuranceRenewal Application

9025 N. Lindbergh Dr. Peoria, IL 61615Name & Mailing Address: Return form to RLI by:

Policy Expiration Date:Policy Number:

Billing Address:

Primary Residence Address:


PLEASE REVIEW AND COMPLETE QUESTIONS 22-24 AND SIGN THE APPLICATION ON THE REVERSE SIDE

Our records show the following information on your file. Carefully review the information for accuracy. If any of theinformation is incorrect, please print the correct answer in the boxes provided. See Page 3 for Definitions andQuestion Details.

1. How many motorized vehicles licensed for road use (i.e., motorhomes, motorcycles, cars, etc.) are owned, leased, rented, or regularlyoperated by you or any member of your household?

Questions15-21

Carefully read questions 15 through 21 and check the box for each question that has a "Yes" response. All members of your household should be considered when answering these questions. See Page 3 forDefinitions and Question Details.

Check If"Yes"

3. How many watercraft, other than canoes, jet skis, waverunners or other personal watercraft, are owned or regularly operated by you orany member of your household?

4. How many jet skis, waverunners or other personal watercraft are owned or regularly operated by you or any member of yourhousehold?

5. How many drivers are in your household? (Include any member of your household with a learner’s permit or a valid driver’s license)

6. How many drivers are under the age of 22? (Include any member of your household with a learner’s permit or a valid driver’s license)

7. How many drivers are age 70 or over? (Include any member of your household with a valid driver's license)

8. How many moving violations have all drivers had within the last 3 years? Include DWI/DUI incidents within the last 5 years or 3 yearsin Montana. (Update question 25)

9. How many at-fault accidents have all drivers in your household had in the last 3 years? (Update question 25)

10. How many antique, classic and/or collectible vehicles are owned by you or any member of your household?

2. How many residential properties are owned or rented by you or any member of your household? 1-4 family units are eligible andshould be counted as one property.

15. Have you or any other driver had an arrest, citation or conviction for reckless driving, careless driving (with 4 points in FL) negligentdriving and/or had a driver's license suspended (for reasons other than driving under the influence of alcohol or drugs), revoked orrefused in the last 5 years or 3 years in Montana? (Careless or negligent driving N/A in SC)

16. Have you or any member of your household been indicted, charged with or convicted of a felony within the last 5 years?

17. Do you or any member of your household have an occupation of a professional entertainer or athlete, media personality, or anappointed or elected federal or state political figure? (N/A for political figures in FL, OR & TX)

E-mail Address:

12. How many acres of timberland and/or land that is farmed, for which the liability coverage is provided by a Homeowners, Farmowners orFarm Comprehensive Personal Liability Policy do you or any member of your household own or lease? (Including partial ownership)

14. How many arrests, citations or license suspensions for driving under the influence of alcohol/drugs and/or driving while intoxicatedand/or any other alcohol/drug related incidents have all drivers had in the last 5 years or 3 years in Montana?

11. How many residential properties owned or rented by you or any member of your household are located outside Canada, Puerto Ricoor the U.S. (including U.S. territories and possessions)?

UpdateBelow

18. Do you or any member of your household own (including partial ownership) 6 or more residential properties rented to others that arenot occupied in whole or in part at any time by you or any member of your household? 1-4 family units are eligible and should becounted as one property.

13. How many driving incidents have all drivers ages 20-21 and/or age 80 or over had within the last 3 years?

19. Has any one driver had more than 3 moving violations within the last 3 years? (Include DWI/DUI incidents within the last 5 years or 3years in Montana.)

20. Has any driver under the age of 20 had a driving incident within the last 3 years?

21. Has any one driver ages 20-21 or age 80 or over had more than one driving incident within the past 3 years?

PUP 207 (01/11)

_________________________________


The named insured may be a maximum of two individuals, provided both individuals reside in the same household. This policy cannotbe issued in the name of an estate, trust or LLC. This form must be completed, signed and dated by a named insured.

of 3 pages PUP 207 (01/11)

23. Carefully read the following statement in italics: that you and all members of yourhousehold agree to maintain these same MINIMUM REQUIRED LIMITS OF LIABILITY coverage outlined in the chart onPage 3 as a condition of your coverage for all licensed vehicles that are owned, leased, rented, operated or acquired atany time during the policy period. You agree that this condition applies equally to personal use of a vehicle under aCommercial Automobile Liability Policy. If you have a driver under the age of 22 in the household, refer to Limit A in thechart on Page 3 for the required limit information. NOTE: The response you previously provided regarding yourAutomobile Liability coverage is in the box to the right.

IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: I understand that as part of the underwriting procedure, aconsumer report may be obtained or an investigative consumer report may be prepared. Such reports may include information regardingmy driving record, credit history, general reputation, personal characteristics and mode of living. I hereby consent to the preparation ofsuch reports and the disclosure of such reports to RLI Insurance Company and the producer of record. I understand that these reports willbe handled in the strictest confidence, and that information as to the nature and scope of these reports will be provided to me uponrequest.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerningany material fact thereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civilpenalties.

APPLICANT STATEMENT: Read Carefully Before Signing. The information given on this form is true and complete to the best of myknowledge. I understand that any omission or misstatement of fact in the information given voids the policy. I further understand that, for anadditional premium, Excess Uninsured or Underinsured Motorist (UM/UIM) coverage is offered and I must elect the coverage in writing. Iagree that Minimum Primary Limits or Basic Policies outlined on page 3 are required and will be maintained during the policy period andthat no insurance will be in effect until RLI issues a Policy. I agree that I will acquire and maintain Minimum Required Limits of Liability forall additional exposures (drivers, houses, vehicles, watercraft, etc.) if they become applicable during the Policy period. I should contact mylocal insurance agent to confirm adequate basic limits for all exposures that are covered under this Policy or that I might acquirethroughout the Policy period.

Informationon File

UpdateBelow

APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT'S ORIGINAL SIGNATURE.If a Power of Attorney is used, a copy of the Power of Attorney letter must accompany the Application.

Applicant's Daytime Phone #_____________________OriginalSignature____________________________________________________ Date _______________________________

22. Carefully read the following statement in italics. that you and ALL members of your household agree tomaintain the MINIMUM REQUIRED LIMITS OF LIABILITY coverage outlined in the chart on Page 3 as a condition of your coverage. For thoselimits that currently do not apply to you or any member of your household, you agree to maintain those limits if they become applicable to youor any member of your household during the policy period as a condition of your coverage.



Questions22-24 Carefully read questions 22 - 24 and refer to the charts on Page 3.

Please refer to Page 3 for Definitions and Question Details.


Question25

Complete the following for all members of your household age 14 and older. Also include on this list any other peoplewho operate a vehicle owned, leased, rented or regularly operated by you or a member of your household at least 50%or more of that vehicle's use.

Date of Birth

Licensedor

Permit?Y/N

Drivers Licenseor


Applicant

DWI/DUIY/N

At-FaultAccidents

(3 yrs)

Violations 3yrs(Incl. DWI/DUI

5 yrs/3 yrs in MT)

Number of:

24. Do you elect to purchase Excess Uninusured/Underinsured Motorists coverage for an additional premium? Circle one.Refer to the attached Purchase/Rejection form for information on

this coverage. No response will result in a rejection of this coverage and your policy will continue to exclude Excess UM/UIM.

If you are unsure what underlying coverage limits you are carrying or are required to carry, we suggest contacting your local brokering agent.

NOTE: RLI now offers Excess UM/UIM in your state.UM/UIM

EXCLUDEDPurchase

orReject

Circle One

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Excluded is the prefilled response on all new Excess UM/UIM states, as it was not available on the policy previously.

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If renewal applicant does not circle one, or fill out attached form, application will be billed without coverage.

of 3 pages PUP 207 (01/11)





-OR- If the answer to Question 14 is >0

-OR-In KS and MA, if there are drivers with 6 yearsor less driving experience in the household.




Excess UM/UIM is not available if you maintain Limit C.

Question 23 and 24:

Limit A

Definitions

"You," "Your," and "I" means the applicant.

"Member of your household" means your spouse and any person related to you by blood, marriage or adoption who either lives with you or is away atschool and anyone who lives with you and is in your or a relative's care or custody.

"Driver" means "you" and "members of your household" who operate motor vehicles licensed for road use, plus any other person who operates avehicle owned, leased, rented, or regularly operated by you or a member of your household at least 50% or more of that vehicle's use.


"At-Fault Accident" includes any single or multi-car accident chargeable under a primary auto policy, any accident resulting in any payment for bodily injuryor property damage, any single car accident resulting in a payment to an insured (unless caused by an animal), and/or any accident resulting in a citation toyou or a member of your household with or without a conviction or final adjudication.

"Antique, classic or collectible vehicle" includes private passenger vehicles more than 20 years old, licensed for road use, driven less than 2,500 milesannually, owned for limited pleasure use, car shows and club events and insured under a Collectors Automobile Policy.

"Personal watercraft" includes small but powerful motorized watercraft sold under brand names such as Jet Ski and WaveRunner usually used by 1-3people and under 14 feet in length.

Question Details

Question 1: Include company vehicles provided for your use or for use by a member of your household. All vehicles licensed for road use need to becounted regardless of individual insurance. Full Timers should count their RV as a vehicle and not a residence. Do not count antique, classic or collectiblevehicles covered under a Collectors Automobile Policy. See Question 10.

Question 2: Primary residences must have liability coverage under a policy containing Comprehensive Personal Liability (including Homeowners andFarmowners). Seasonal, secondary or rental properties may have liability coverage under a Comprehensive Personal Liability or Premises Liability Policy.Do not include residential properties that are covered under a Commercial General Liability Policy or other non-personal Premises Liability Policysince they are excluded from coverage.

Question 3: Count only watercraft between 14 and 45 ft. and with a maximum speed of 50 mph. Watercraft exceeding these limitations are excludedfrom coverage.

Question 6: In KS and MA, count only those drivers with six years or less driving experience. Driving with a permit is not considered driving experience andshould not be included within the six years as driving experience.

Question 8: In Florida, count only moving violations with 1 or more points assessed to the drivers license.

Question 22:



PERSONAL LIABILITY



PERSONAL LIABILITY


FARMOWNERS OR FARM COMPREHENSIVEPERSONAL LIABILITY

(Required only if you or any member of yourhousehold own a farm that is not covered




(Required only if you or a member of yourhousehold own or acquire an unlicensed

recreational vehicle during the policy period that is not covered by your homeowners

or personal liability policy for the following limits of liability.)


-OR- $100,000/$300,000/$25,000



(Required only if you or a member of yourhousehold own or acquire a watercraft duringthe policy period that is not covered by yourhomeowners or personal liability policy for

the following limits of liability.)


$250,000/$500,000/$100,000-OR-

$300,000/$300,000/$100,000

NOTE: The RLI Personal Umbrella does notprovide coverage for watercraft exceeding 45 ft and/or 50 mph. This exclusion does

not apply to personal watercraft.

Limits B and C are available options ONLY if all drivers in the household are age 22 and over.Limit C is NOT available if there are any drivers age 70 or over in the household.





$300,000 Combined Single Limit per occurrence($325,000 in TX)

Limit B Limit C

If you elect to purchase Excess UM/UIM coverage, the Required Basic UM/UIM Policy Limits must be equal to the liability limits for the Required BasicAutomobile Liability policy.



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Illustrates the need to have your underlying UM/UIM limits match your underlying auto.

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Shows that you must maintain higher limits of A or B to be eligible for Excess UM/UIM coverage.

Dear Policyholder,

It is time to update your file so that we can renew your RLI personal umbrella policy.

Please note that your agent does not receive a copy of this information. It is your responsibility to complete this formand return it to RLI to renew your coverage. However, your Brokering Agent can provide guidance on coverages orassistance with completing the form. Your Brokering Agent’s name and phone number are highlighted on theattached application. If you do not return this application, we will not have the information needed to determine yourrenewal coverages and premium, and your policy will not be renewed.

The form is quick and easy to complete. Just follow these 6 simple steps:

1. Check your name and address on the application. Write any changes next to this information. Have you moved?No problem! RLI offers personal umbrella protection in all 50 states and DC.

2. For your convenience, we have pre-filled your prior answers, when available, to questions 1-14. Please reviewthese answers and correct them, as necessary, with updated information. Carefully read questions 15-21 andanswer “YES” if the question applies to you or any member of your household. Questions 22 and 23 are aboutyour Basic Limits. When you sign the renewal application, you agree to maintain the required minimumunderlying limits specified on page 3 of this application. If your auto limits have changed, please note this onquestion 23.

3. Excess UM/UIM coverage is now offered in your state. Please refer to question 24 and the attachedPurchase/Rejection form which will provide some very basic information on the estimated cost and the coverageprovided. Because RLI did not previously offer this coverage, your application is pre-filled with EXCLUDEDindicating that you currently do not have this coverage. If you wish to purchase Excess UM/UIM coverage, circlePURCHASE on the questionnaire and your bill will reflect the additional charge. If you have any questions abouthow this coverage applies to you or your family, contact your Brokering Agent.

4. Complete and/or verify ALL INFORMATION in the chart for question 25 for any member of your householdage 14 and over, whether they are licensed to drive or not. There should be no blanks in the chart for anyindividual listed. If the question does not apply to that individual, insert a “0”.

5. Sign and date the application. If this form is signed by a power of attorney or other representative of the insured,please attach the appropriate legal paperwork. Return the signed application to RLI in the envelope provided.

6. Note this is a 3 page form. Bolded words in the questions are defined terms in your policy and Page 3 containstheir definition and other helpful information to assist you when answering the questions.

Why do we need this information? Changes in your life and in your home and auto insurance coverages may impactthe premiums we charge (many times they go down!). Once we receive this information, you will receive an invoiceto continue coverage or, in some cases, an explanation for why we may no longer be able to offer coverage.

Thank you for putting your trust in RLI. We look forward to the opportunity to protect you in the future.

QRN 12 (01/11)

IMPORTANT NOTICE ABOUT RENEWING YOUR PERSONAL UMBRELLA POLICY





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Note: This is the renewal cover letter that will be attached to the renewal apps in the new Excess UM/UIM states.

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Highlights the importance of speaking to agent for assistance.

Dear Policyholder:

Thank you for renewing your RLI Personal Umbrella policy! Your Renewal Declaration and policy documentsare enclosed. Please review them carefully. This coverage provides personal liability protection above theBasic Policy limits described on your Renewal Declarations Page. As an RLI personal umbrella policyholder,you have the peace of mind that comes with knowing your personal assets are well-protected.

If you have any questions regarding your policy, the coverage it provides, or if you need to make a claim,contact your insurance representative. Their contact information is listed on your Renewal Declarations Page.

Once again, thank you for your business.

Sincerely,

Page 1 of 2 PUP 118 (01/11)

9025 N. Lindbergh Dr. | Peoria, IL 61615-1431RLI Insurance Company

PUP 118 (01/11)


Certain coverages in this policy have been revised to clarify our intentrelative to personal umbrella coverages. These new provisions PUP320(04/10) have been filed and approved by the Department of Insurancein your state.

RLI’s personal umbrella policy is intended to be additional liabilitycoverage over and above the Insured’s Basic Policies. Since the policyprovisions of the Basic Policies are referenced throughout the RLIpolicy provisions, you should also be well aware of the coveragesafforded by the Basic Policies. Your local agent who sold you thepolicy is the best resource to discuss your specific questions.

RLI now offers Excess Uninsured/Underinsured Motorists coverage inyour state as of January 1, 2011. The coverage you elected on yourrenewal application is shown on the declaration page.

RLI PERSONAL UMBRELLA

POLICYHOLDER NOTICE

Page 2 of 2 PUP 118 (01/11)

9025 N. Lindbergh Dr. | Peoria, IL 61615-1431RLI Insurance Company

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BILLING

RENEWAL BILLING

PUP 600 (01/11)

Your personal assets and your future earnings deserve an extra layer of protection. RLI can provide up to $5 million in coverage.

Policy Number:

Expiration Date:

Policy No. Due Date Full Payment by date due continues this policy to:

Balance Due: Amount Enclosed:

RLI Insurance CompanyPersonal Umbrella Liability Insurance

401 Please detach and return bottom portion with your payment. See reverse side to pay online at www.myrli.com.

RLI Insurance Company Personal Umbrella Liability Insurance

Please include check payable to: RLI Insurance CompanyPlease check box to indicate a change of address.

For credit card payment, please check box andcomplete information on back.

RLI Insurance CompanyP.O. Box 4726Carol Stream, IL 60197-4726

Overnight Mail: RLI Insurance Co. RRLB 4726JP Morgan Chase Bank, N.A.IL1-60302500 Westfield DriveElgin, IL 60124

RLI Insurance Company9025 North Lindbergh Drive Peoria, Illinois 61615

Pup Bill

4726 2310130001001 253025 0339702 20080510 0025300 01 00011 1

$1 Million Premium

$2 Million Premium

$3 Million Premium

$2 Million Premium $3 Million Premium

We appreciate the opportunity to provide your personal umbrella coverage. In today's litigious society, apersonal umbrella may be your most important insurance protection. However, this valuable coverageexpires / / . To renew this policy for another year, please see the reverse side for information on how to payby credit card online. You may also send a check or credit card information in the enclosed envelope for thecoverage limit you desire, along with the bottom portion of this form. Payment must be received by RLI no laterthan / / . If your premium is not received by that date, coverage will lapse effective / / . You currently have a$1 million policy limit. We encourage you to consider carrying the maximum available limit shown above. If youare unsure what coverage limit is needed, you should contact your insurance agent.


$5 Million Premium

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Excess Uninsured/Underinsured Motorists Coverage has been accepted. Excess Uninsured/Underinsured Motorists Coverage has been rejected. Excess Uninsured/Underinsured Motorists Coverage is not available in your state. Excess **UM or UIM** Motorists Coverage at a limit of $100,000/$300,000 has been *added or deleted**.

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These are examples of the statements that will appear depending on what has been selected.

Change of Address Information: Please check one: Mailing address Primary address Billing address

Name: ________________________________________________________________________________________________

Address:_______________________________________________________________________________________________

CREDIT CARD TYPE: VISA MASTERCARD

CREDIT CARD NO.

AMOUNT TO BE CHARGED EXP. DATE

If the credit card transaction is denied for any reason, the policy is subject to cancellation for non-payment of premium, and Iagree to make necessary payments that are due to RLI Insurance.

SIGNATURE ___________________________________________________ DATE _________________________________

To pay for your RLI Personal Umbrella coverage online:

Log onto www.myrli.comEnter your user name:Enter your password:

Only Internet Explorer version 6 and later can beused for online payments.

REVISED RENEWAL BILLING

PUP 605 (01/11)


Policy Number:Expiration Date:

Policy No. Due Date Full Payment by date due continues this policy to:

Balance Due: Amount Enclosed:









4726 2310130001001 253025 0339702 20080510 0025300 01 00011 1

$1 Million Premium $




We recently sent you a bill for the renewal of your personal umbrella coverage based upon your completedrenewal application. Subsequent to that time, we have received additional information which has revised yourrenewal premium. The premium has changed due to the following:

To renew this policy for another year, please see the reverse side for information on how to pay by credit cardonline. You may also send a check or credit card information in the enclosed envelope for the coverage limityou desire, along with the bottom portion of this form. Payment must be received by RLI no later than / / ; ifyour premium is not received by that date, coverage will lapse effective / / .



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Excess Uninsured/Underinsured Motorists Coverage has been rejected. Excess Uninsured/Underinsured Motorists Coverage has been accepted. You have accepted Excess Uninsured/Underinsured Motorists Coverage equal to the limits of your Personal Umbrella Liability Policy. You have rejected Excess Uninsured/Underinsured Motorists Coverage equal to the limits of your Personal Umbrella Liability Policy. Excess **UM or UIM** Motorists Coverage at a limit of $100,000/$300,000 has been **add or delete**. The Excess Uninsured/Underinsured Motorists Limit of Coverage has been changed from $000.00 each accident to $000.00 each accident.

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These are examples of the statements that will appear depending on the individual circumstances.


Name: ________________________________________________________________________________________________

Address:_______________________________________________________________________________________________


CREDIT CARD NO.


SIGNATURE ___________________________________________________ DATE _________________________________





ENDORSEMENT BILLING

PUP 620 (01/11)


Policy Number:

Expiration Date:

Endorsement Premium:

Policy No. Due Date Balance Due

Full Payment by date due continues this endorsement to:Amount Enclosed:










4726 2310130001001 253025 0339702 20080510 0025300 01 00011 1

You have requested that RLI endorse your policy effective as follows:

The additional premium due as a result of this request is $ .

Please see the reverse side for information on how to pay the balance due by credit card online. You may alsosend a check or credit card information in the enclosed envelope for the balance due, along with the bottomportion of this form.

Payment must be received by RLI no later than ; if the additional premium is not received by that date, RLI willnot endorse your policy as requested.

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Endorsement will be completed and effective on the requested date if the additional premium is paid by the due date. This will be the case for all available money endorsements including UM/UIM.

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Add Excess Uninsured/Underinsured Motorists Coverage. Increase the Policy Limit has been increased from $**1** million to $**2** million. Change the Excess Uninsured/Underinsured Motorists Limit of Coverage from $000.00 each accident to $000.00 each accident.

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Callout

These are examples of the statements that will appear depending on what has been selected.


Name: ________________________________________________________________________________________________

Address:_______________________________________________________________________________________________


CREDIT CARD NO.


SIGNATURE ___________________________________________________ DATE _________________________________





Effective Date of

Attached to and forming a part of the policy of the RLI Insurance Company. All other terms and conditions remain unchanged.

Policy NumberNamed Insured Agent


PUP 330 (01/11)

POLICY CHANGE ACKNOWLEDGMENT

Duplicate 02-24-205

Change 02-24-2005

___________________________________________________________________________________________________________Insured's Brokering Agent: SubProducer Name (000) 000-0000

MB32165423

Insured Name goes here 32165Insured Mailing Address goes here Broker Name goes hereInsured Mailing Address goes here Broker Mailing Address goes here

Broker Mailing Address goes hereInsured Mailing Address goes hereBroker Mailing Address goes hereInsured Mailing Address goes hereBroker Mailing Address goes here

PUP 330 (01/11)PREVIEW


A Stock Insurance Company

The Policy Limit has been changed from $000.00 million to $000.00 million.Excess Uninsured/Underinsured Motorists Coverage has been **added or deleted**.Excess Uninsured/Underinsured Motorists Coverage has been **added or deleted **.Your Agent's account has been **credited or info per rule**.Excess Uninsured/Underinsured Motorists Coverage has been *added or deleted *.Refund amount of $000.00 to follow.The Excess Uninsured/Underinsured Motorists Limit of Coverage has been changed from $000.00 each accident to $000.00 each accident.Excess *UM or UIM* Motorists Coverage at a limit of $100,000/$300,000 has been *added or deleted*.


RE:

RLI received a request to endorse your coverage as follows:

PUP 722 (01/11)

M


Request to amend coverage effective / / .

PUP 722 (01/11)

RLI did not receive payment for this requested endorsement, and as a result, your coverage with RLI has notbeen changed.

Regards,


Cc:

tflanaga

Callout

Coverage must be paid, for in order for it to be added.

excess um/uim overview 1-1-2011 3-1-2011 · excess um/uim overview v1 10/14/2010 excess um/uim...

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