Kidnap & Ransom Coverage Application — Company / Organization
Please complete the application with your organization's details. Have relevant information ready for a smooth process.
Who is completing this application?
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The Applicant
An Insurance Producer
Agent Full Name
First Name
Last Name
Agent Email
example@example.com
Agent Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Agency Name
State Producer License No.
Producer Information
General Information
Name of Applicant
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Street Address
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City
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State
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Zip
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Primary Contact Name and Title
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First Name
Middle Name
Last Name
Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
NAICS Code
Year Established
Email Address
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example@example.com
Applicant Website
Organization Type
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Private
Non-Profit
Publicly Traded
Financial Institution
Total assets as of most recent fiscal year-end (US dollars)
Total employees
Travel and Location Exposure Information
Do directors, officers, or other employees of the applicant take trips outside the United States?
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Yes
No
If yes, list anticipated country destinations for the next 12 months
Approximate number of trip days for employees traveling outside the United States
Does the applicant have any permanent locations outside the United States?
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Yes
No
If yes, list each country with number of locations and number of employees
Loss Control Information
Answer only if requesting a coverage limit greater than $1,000,000.
Does the Applicant have employee travel procedures for travel outside the United States?
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Yes
No
Does the Applicant have safety procedures for employees or permanent locations outside the United States?
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Yes
No
If yes, briefly explain the safety procedures for employees or permanent locations outside the United States.
Does the Applicant take steps to ensure the safety of people and premises permanently located outside the United States?
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Yes
No
If yes, briefly explain the steps taken to ensure the safety of people and premises permanently located outside the United States.
Does the Applicant have a formal crisis management plan?
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Yes
No
If yes, does the plan establish a formal crisis management committee?
Yes
No
Does the Applicant have a security director or similar position?
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Yes
No
If yes, does the position maintain real-time information for employee travel outside the United States?
Yes
No
Requested Insurance Terms
Kidnap for Ransom - Requested Limit (US dollars)
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Kidnap for Ransom - Requested Retention (US dollars)
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Extortion for Ransom - Requested Limit (US dollars)
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Extortion for Ransom - Requested Retention (US dollars)
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Covered Expenses for Detention or Hijack - Requested Limit (US dollars)
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Covered Expenses for Detention or Hijack - Requested Retention (US dollars)
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Loss of Ransom in Transit or Delivery - Requested Limit (US dollars)
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Loss of Ransom in Transit or Delivery - Requested Retention (US dollars)
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Rest and Rehabilitation Expenses - Requested Limit (US dollars)
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Rest and Rehabilitation Expenses - Requested Retention (US dollars)
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Personal Accident - Requested Limit (US dollars)
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Personal Accident - Requested Retention (US dollars)
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Covered Expenses for Kidnap or Extortion - Requested Limit (US dollars)
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Covered Expenses for Kidnap or Extortion - Requested Retention (US dollars)
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Legal Liability - Requested Limit (US dollars)
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Legal Liability - Requested Retention (US dollars)
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Crisis Response Firm Fees and Expenses - Requested Limit (US dollars)
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Crisis Response Firm Fees and Expenses - Requested Retention (US dollars)
*
Loss Information
Has the Applicant or any person proposed for this insurance been involved in a kidnapping, detention, hijacking, or extortion for ransom incident during the past 3 years?
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Yes
No
Date of incident
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-
Month
-
Day
Year
Date
Amount of loss
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Description of the incident
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Corrective procedures implemented
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Declaration & Signature
Authorized Representative Name
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First Name
Middle Name
Last Name
Title
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Date
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-
Month
-
Day
Year
Date
Electronic Signature Acceptance
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I confirm that the statements made in this application are true and complete to the best of my knowledge and belief.
Submit
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