Group personal excess liability insurance from chubb Enrollment Form

Name _________________________________________________________________________________________________________

mailiNg address ______________________________________________________________________________________________

e-mail address _______________________________________________________________________________________________

daytime PhoNe ________________________________________________________________________________________________

Fortress Policy No.: __________________________

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.

Coverage term: the first day of the next month to october 1, of the current year.

excess liability excess um/uim

Excess Liability Premium Choice UM/UIM Premium Choice Limit with $1M UM/UIM Limit

$1 million $250 $2 million $80

$2 million $325 $3 million $160

$3 million $450 $5 million $320

$5 million $500

$10 million $875

$15 million $1335

$20 million $2140

$25 million $2675

Note: to calculate your total annual premium, add the premium charge for the selected excess liability limit to the premium charge for selected Um/Uim limit.

total Annual Premium $ _____________ _

to finish the enrollment process:1. direct any questions to your local Fortress agent.

2. Complete and sign this form and send it to your Fortress agent.

3. the prorated premium will be provided by your Fortress agent.

4. refer to policy highlights brochure or www.mygroupexcess.com to make sure you have the minimum required limits

on your underlying policies.

5. mail this form and remittance to your local Fortress agent.

sigNatUre __________________________________________________________________ date __________________________

Excess liability must match or be greater than UM/UIM limits

Chubb refers to the insurers of the Chubb group of insurance Companies underwriting coverage. For a full list of insurers, please visit www.chubb.com. Not all insurers do business in all jurisdictions.

Chubb Personal insurance (CPi) is the personal lines property and casualty strategic business unit of Chubb & son, a division of Federal insurance Company, as manager and/or agent for the insurers of the Chubb group of insurance Companies.

this literature is descriptive only. actual coverage is subject to the language of the policies as issued. Chubb, P.o. Box 1615, Warren, NJ 07061-1615

Form 06-01-0061 (rev. 6/14) Voluntary - Fortress www.chubb.com/personal