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Personal Liability Umbrella Application
Application for Personal Liability Coverage for AICPA Members
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STEP - 1
Important
For your security, you have 23 minutes to complete each step of the application process. If there is a period of more than 23 minutes of inactivity throughout any step of the process, the process will terminate and you will need to restart from the beginning. Each step is completed when you click the Continue button.
To complete and submit this application, you will be required to provide the following information:
The driver's license numbers/driving history, if applicable, and social security numbers of each household member age 15 or older
You will be given the opportunity to review your answers before submitting the application. After you submit the application, a copy of your completed application will be available to print and retain for your records.
Required fields
*
Continental Casualty Company - A CNA Company
Personal Catastrophe Liability Application
Are you a member of the AICPA or an employee of a firm with AICPA membership?
*
Yes
No
If "No" you are not eligible for Personal Liability Insurance under the AICPA Insurance Programs.
Applicant's Name and Personal Residence
*
First Name
Middle initial
*
Last Name
*
Address 1
Address 2
*
City
*
Residence State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
*
Zip
*
Daytime Telephone Number
(
)-
-
Email Address
*
Please select coverage desired:
*
Yes
,
this application is for increased coverage.
If Yes, enter policy number found on your policy details page:
410
Requested Effective Date:
*
01
02
03
04
05
06
07
08
09
10
11
12
/ 1 / 20
Note:
Coverage begins on the first day of the month following approval of your application. This plan has an annual renewal date of November 1st so if you buy at another time of year, your premium will be pro-rated. Your first annual renewal will be due the next November.
Personal Liability Limit
$1 Million
$2 Million
$3 Million
$4 Million
$5 Million
Optional UMC
Notice applicable to members living in Indiana, Louisiana, New Hampshire, Vermont, West Virginia and Wyoming only.
Uninsured and Underinsured Motorists Coverage(UMC) - UMC Notice
UMC is insurance for possible injury to you, caused in an automobile accident by someone who has no insurance or inadequate insurance. AICPA PLUS Plan personal liability covers your liability to others. You may purchase optional UMC up to the limit of your personal liability coverage or a lower available amount.
Optional UMC Limit
$1 Million
$2 Million
$3 Million
$4 Million
$5 Million
None
If a UMC limit is selected your policy will include the coverage and the additional premium
ELECTION NOT TO ACCEPT OFFER OF UMC
I have been offered the opportunity to purchase UMC under the PLUS Plan. I elect not to include UMC under the PLUS Plan. It is agreed that this rejection of UMC will hold in any renewal, supplementary, replacement or substitute policy.
Yes
I have read the UMC Notice and I reject the coverage on behalf of all who are to be covered by this policy.
Annual Premium - Personal Liability: $
Annual Premium - Optional UMC: $
Please select coverage desired:
*
Yes
,
this application is for increased coverage.
If Yes, enter policy number found on your policy details page:
410
Requested Effective Date:
*
01
02
03
04
05
06
07
08
09
10
11
12
/ 1 / 20
Note:
Coverage begins on the first day of the month following approval of your application. This plan has an annual renewal date of November 1st so if you buy at another time of year, your premium will be pro-rated. Your first annual renewal will be due the next November.
Personal Liability Limit
$1 Million
$2 Million
$3 Million
$4 Million
$5 Million
Optional UMC
Notice applicable to members living in Florida only.
Uninsured and Underinsured Motorists Coverage (UMC) - UMC Notice
UMC is insurance for possible injury to you, caused in an automobile accident by someone who has no insurance or inadequate insurance. AICPA PLUS Plan personal liability covers your liability to others. You may purchase optional UMC $1 million limit in addition to your personal liability.
Optional UMC Limit
$1 Million
None
If a UMC limit is selected your policy will include the coverage and the additional premium
ELECTION NOT TO ACCEPT OFFER OF UMC
I have been offered the opportunity to purchase UMC under the PLUS Plan. I elect not to include UMC under the PLUS Plan. It is agreed that this rejection of UMC will hold in any renewal, supplementary, replacement or substitute policy.
Yes
I have read the UMC Notice and I reject the coverage on behalf of all who are to be covered by this policy.
Annual Premium: $
Annual Premium - Optional UMC: $
Please select coverage desired:
*
Yes
,
this application is for increased coverage.
If Yes, enter policy number found on your policy details page:
410
$1 Million
$2 Million
$3 Million
$4 Million
$5 Million
Requested Effective Date:
*
01
02
03
04
05
06
07
08
09
10
11
12
/ 1 / 20
Note:
Coverage begins on the first day of the month following approval of your application. This plan has an annual renewal date of November 1st so if you buy at another time of year, your premium will be pro-rated. Your first annual renewal will be due the next November.
Annual Premium: $
