:: Personal Excess Liability Program ::

Company Name : Northwestern Mutual Life Insurance Company

Field Agents of Northwestern Mutual Personal Excess Liability Program

I choose to not purchase this coverage (Please complete the First Name, Last Name, Employee Number and Email Address fields, then electronically sign and submit the form.)

Applicant First Name* :

Applicant Last Name* :

Employee Number :

Company Name :

Address 1* :

Address 2 :

City* :

State* :

Zip* :

Telephone* :

Email* :

Policy Year* :

Limits of Liability	Uninsured/Underinsured Motorist Participant	Rate Per Year
$1,000,000	1,000,000	$913.61
$2,000,000	1,000,000	$1,269.99
$3,000,000	1,000,000	$1,474.96
$5,000,000	1,000,000	$1,797.35
$10,000,000	1,000,000	$2,890.18
$15,000,000*	1,000,000	$7,079.19

Limit of Liability:*

Note: All Uninsured Motorist (UM/UIM) participant in a limit of $1,000,000. We have higher limit options, please see below:

$2,000,000

Add an additional $221.00

$3,000,000

Add an additional $449.00

$5,000,000

Add an additional $917.00

Annual Premium (based on your selection) : $

Total Due (based on your selection) : $

Requested Effective Date* :

To be eligible for this additional excess liability coverage, Chubb requires the following underlying limits to be in-force.

Hays Companies is not responsible if you have a gap in coverage. Please talk to your agent and verify the following limits are in-force :

Coverage	Limits
Personal Liability	$300,000
Registered Vehicle Liability	$250,000/$500,000 Bodily Injury $100,000 Property Damage, or $300,000 CSL
Unregistered Vehicle	$300,000
Registered Vehicles with Less Than Four Wheels Minimum AMS	$250,000/$500,000 Bodily Injury $100,000 Property Damage, or $300,000 CSL
Watercraft Liability 26 feet or more or/more than 50 H.P.	$300,000 $500,000
Uninsured/Underinsured Motorist	$250,000/$500,000 Bodily Injury
Motorist Coverage	$300,000 CSL or $100,000 PD

Policy Effective Period : 08/07/2024 To 08/07/2025

Policy Effective Date : Label

Sign and Acknowledge

* By typing your name into the field below, you are affixing an electronic signature to a legal document and by doing so, you agree to be bound by the terms and provisions set forth in this application.

To bind coverage you need to return this signed application or sign the application electronically and submit online. This is excess coverage over any current excess liability coverage you currently have. Certificate will be delivered via email for your records within 60 days of effective date.

WARRANTY: This application requests information that the group will use to determine whether a policy will be used in preparing a quotation. The applicant warranties that the information presented is correct and complete. In the event this policy is issued, this application will become part of the policy and coverage will be contingent upon the accuracy and completeness of the information provided. No coverage will be approved if the information is found to be materially incorrect, incomplete or unsigned by the applicant.

Submitted by* :

Date :

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