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Kidnap & Ransom/Extortion Corporate Coverage

General Application Information
(Required *)

Name of Corporation: *
Corporate Mailing Address/Street:
City/State/Zip:
Contact Name: *
Phone: *
Fax:
E-Mail: *
Description of Business Operations:
(Describe typical services performed, customers served, products provided, etc.) :
Total Revenue: $
Total Assets: $

Please provide annual report if available. You can fax it to us at 301-417-0040.
 
List Locations of All Employees and the Number of Employees at Each:
Country Total #
 
Do You Have Independent Contractors Working on Your Behalf? If Yes, Add This Information Below. List Location and Number of Contractors at Each Location:
Country Total #
 
List Anticipated Travel by Specific Country, Duration, and Number of Persons:
Specific Country Frequency Duration Total #

 

Has the Applicant or Any Person(s) to be Covered Under This Policy:

a. Ever been declined, cancelled or had a policy issued with special conditions by any insurance carrier?
No Yes
b. Ever received an actual, attempted or threatened kidnapping, extortion, detention or hijacking attempt?
No Yes (if yes, pleae describe below):
c. Have any knowledge or details which may reasonably give rise to a claim? If yes, please provide details to the right:
   
Please State Any Special Security Precautions or Attach Details:
Requested Limits of Liability: $
 
NOTICE TO APPLICANTS: THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, BUT IT IS AGREED THAT THIS APPLICATION WILL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND MADE A PART OF THE POLICY. THE APPLICANT REPRESENTS THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE INCEPTION DATE OF THIS POLICY, THE APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES.
 
        


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