Kidnap & Ransom Application Form

It is important that you complete this proposal as fully as possible.

Organisation

Organisation Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of Organisation Activities

Please complete the following regarding the Insured Organisation’s operations:

	List Countries in which you have operations	Type of Operation	Number of Locations	Number of Employees	Sales & Turnover
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Please provide the following information regarding the foreign of the Organisation’s employees or attach a detailed travel plan.

	Travel Destination by Country	Number of trips per year	Average length of stay	Number of employees travelling
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Please identify any country noted in items 4 and 5 above that you believe present your operations or employees with above average risk to Kidnapping, Extortion, Political Instability and other acts of Terrorism

Please identify any precautions taken to protect those individuals or facilities noted in item 6.a. above:

Please identify the individual in your firm responsible for the organisation’s security:

Name

First NameLast Name

Title

Email

example@example.com

Does the Applicant have any knowledge of specific facts or information, relative to the Insured’s Organisation, that may give rise to a claim under the coverage provided by the requested policy?

If ‘Yes’, please provide details

Please provide details on all network security precautions taken to secure sensitive client data that exists on your corporate networks.

List all kidnapping, extortion threats, cyber extortion, hijacking, wrongful detention or political threats discovered by the Insured Organisation in the last 5 years which would have been covered under the policy for which this Application is made, itemising each loss separately

	Date of loss, threat or event	Description of loss, threat or event	Total amount of loss	Please indicate whether or not the loss was covered under another insurance policy and include the carrier’s name
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Requested Limits of Liability:

Material Change

If there is any material change in the answers to the questions in this Proposal Form before the policy inception date, the Insured Organisation must immediately notify the Company in writing, and any outstanding quotation may be modified or withdrawn.

For the purposes of this Application, the undersigned authorised agents of the person(s) and entity(ies) proposed for this insurance declare to the best of their knowledge and belief, after reasonable inquiry, the statements made in this Application and any attachments or information submitted with this Application, are true and complete. The undersigned agree that this Application and its attachments shall be the basis of a contract should a policy providing the requested coverage be issued and shall be deemed to be attached to and shall form a pat of any such policy. The Company will have relied upon this Application, its attachments, and such other information submitted therewith in issuing any policy. The information requested in this Application is for underwriting purposes only and does not constitute notice to the Company under any policy of a Claim or potential Claim.