Personal Umbrella Liability Quote Request

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What information will you need?
You will need information on any properties owned or rented, activities conducted on your premises, household drivers including license numbers, vehicles you use including recreational and watercraft, current auto/other policy liability amounts, and liability limits desired.¹

First, Tell Us About Yourself . . .

page 1 of 5

Insured first name:

Insured last name:

Are you a DCU member?

yes no

Date of birth:

Occupation:

Employer:

Number of years at employer:

Is there a second insured?

yes: no:

First name (2nd Insured):

Last name (2nd Insured):

Is the second insured a DCU member?

yes no

Date of birth (2nd Insured):

Occupation (2nd Insured):

Employer (2nd Insured):

Number of years at employer (2nd Insured):

Is there an additional insured or trustee?

yes: no:

Mailing address:

City:

State:

Zip:

Home phone:

Cell phone:

Email address:

Do you travel to foreign countries more than 6 months a year?

yes: no:

Any accidents or traffic violations in the past 3 years?

yes: no:

If yes, when and briefly what happened:

Any physical, medical, or mental/emotional impairments?

yes: no:

Involved with unpaid civic duties, volunteer work, a non-profit corporation, or other non-compensated positions?

yes: no:

If yes, please describe:

¹ Insurance companies use information gathered from you and often from outside sources about your insurance claim history, property and credit history. This allows them to determine the proper insurance premium pricing and provide a more accurate quote. Accessing your credit information for this purpose has no impact on your credit rating. By submitting this form, you are authorizing DCU Insurance and/or our insurance carriers to access your insurance reports.

Not NCUA
Insured

No Credit
Union Guarantee

May Lose
Value

DCU Insurance (DCU Financial Insurance Services, LLC) is an affiliate of Digital Federal Credit Union (DCU). Business conducted with DCU Insurance is separate and distinct from any business conducted with the credit union.

Remember that any insurance required as a condition of the extension of credit by DCU need not be purchased from DCU Insurance but may, without affecting the approval of the application for credit, be purchased from an agent or insurance company of the member's choice.

Insurance products are not deposits of DCU and are not protected by the NCUA. They are not an obligation of or guaranteed by the credit union and may be subject to risk.

If you have any concerns or complaints regarding this relationship, you may contact the MA Office of Consumer Affairs, or the insurance department of your state. For information on how to contact them, you may call us.