Group Personal Excess Enrollment Form

PLEASE SELECT ONE:
I choose TO purchase Chubb Group Personal Excess Liability Insurance and the Excess Uninsured/Underinsured Motorist Protection (UM/UIM) Coverage* in the amount selected below.

Furthermore, I agree that an annual automatic draw/payroll deduction (as applicable) for the full annual premium I selected, will be taken from my pay, upon the policy effective date each year.
OR
I choose to NOT purchase Chubb Group Personal Excess Liability Insurance.

Excess Liability
Must select one
Excess UM/UIM
Must select one
Excess Liability
Limit
Annual
Premium
Choice UM/UIM
Limit
Annual
Premium
Choice
$1 million $336.00 $1 million Included
$2 million $453.00 $2 million $75.00
$3 million $477.00 $3 million $150.00
$5 million $567.00 $5 million $300.00
$10 million $1,040.00
$15 million $1,543.00
$20 million $2,456.00
$25 million $3,045.00
$50 million Call to discuss

TOTAL:


By entering your name you agree that it is the same as signing.
  • Questions? Call Brad Wittenbaum at 513-985-3600
  • Option: Fax your paper enrollment form to Brad at 513-985-3606
  • Option: Scan and email your paper enrollment form to brad@spagency.com
  • NO COVERAGE IS BOUND AT THIS TIME
  • YOU WILL BE NOTIFIED IN WRITING ONCE THE REQUIREMENTS TO ISSUE ARE MET AND THE POLICY IS IN FORCE
  • IF APPLICABLE, DO NOT CANCEL OR CHANGE ANY PERSONAL INSURANCE COVERAGES WITH YOUR CURRENT AGENT UNTIL NOTIFIED TO DO SO
  • THE COVERAGE PROVIDED UNDER THIS POLICY IS NOT CONVERTIBLE TO A PERSONAL UMBRELLA POLICY. IF YOU LEAVE THE GROUP, YOUR COVERAGE UNDER THIS GROUP POLICY WILL TERMINATE AT THE END OF THE CURRENT POLICY TERM. PLEASE CONSULT WITH YOUR PERSONAL INSURANCE AGENT/COMPANY (OR BRAD WITTENBAUM) IF REPLACEMENT COVERAGE IS DESIRED.