Menger Underwriting Services - Sample Files

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SAMPLE FILES: ENTRY FORM - EXCESS LIABILITY

SAMPLE ONLY - do not enter data here

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	ID Number:
	User Name:
	User e-mail:
	Producer:

Underlying Insurance Policies
COMPANY	POLICY NUMBER	EXPIRES


Excess Insurance Policy
COMPANY

Item 1. Named Insured(s):

Name
Name
Address
City
State
Zip

Name and Address of Additional Insured(s)

Item 2. Policy Period: From To
Both Days at 12:01 A.M. Local Time.

Item 3. Limits:

COVERAGE LIMITS:	UNDERLYING POLICY LIMITS	EXCESS POLICY LIMITS	TOTAL LIMITS
Bodily Injury
Property Damage
Each Occurrence

D. COVERAGE INSURED HEREON, as provided by the underlying carrier

(a) Aircraft Liability Including PassengersE:xcluding Passengers

(b) Airport Liability Including Bodily Injury and Property Damage

E. INFORMATION, as provided by the underlying carrier

(a) Including Extended Liability coverage for:
Premises Products Non-owner Personal Injury Additional Insureds

(b) Including Extended Liability coverage for:
Premises Products Contractual Personal Injury Hangarkeepers

Item 4. Risk Description - Other:

Loc/N#	Aircraft/Description

Item 5. Premium:

Item 6. Endorsements attached and Policy Warranties ON THIS POLICY at time of issue:

Number	Description	Name

ENTER RATE CODE FROM QUOTE SHEET --- HERE

Sec.

Cov.

#Acft

PML

Use

State

Seats

Sec.

Cov.

PML

Use

State

Loc

IV.

OLT

PRD

CNT

II.

HKL

III.

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