BTA – TEST FORM | AHT Insurance

Submission Date

Quote Due Date

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Name of Organization

Phone Number

SIC Code (If known)

Number of Years in Business

Total Revenues: $

Total Assets: $

BENEFITS

Accidental Death (Only)

Paralysis

Security Evacuation

Kidnap & Ransom

Accidental Death & Dismemberment

Supplemental Out-of-Country Accident & Sickness Medical

Baggage Loss / Personal Effects

Additional Benefits (Describe)

RISK INFORMATION FOR U.S. DOMESTIC EMPLOYEES

Please complete the following table. (A travel day is any day or part of a day that the Insured Person is away from his or her regular place of the business on the business of the policyholder; for example, trip to bank, lunch with client, sales call, etc.) Mark “N/A” if the information does not apply

Total Number of Employees

Total Number of Employees to be Covered

Class 1 - Description

Class 2 - Description

Class 3 - Description

Class 1 - Number of Employees

Class 2 - Number of Employees

Class 3 - Number of Employees

Class 1 - Benefit Amount / Salary Multiple

Class 2 - Benefit Amount / Salary Multiple

Class 3 - Benefit Amount / Salary Multiple

Risk Information for International Employees

For each country where employees reside, copy the following table and complete. (A travel day is any day or part of a day that the Insured Person is away from his or her regular place of the business on the business of the policyholder; for example, trip to bank, lunch with client, sales call, etc.)

Class 1 - Number of Employees

Class 2 - Number of Employees

Class 3 - Number of Employees

Class 1 - Principal Sum / Salary Multiple

Class 2 - Principal Sum / Salary Multiple

Class 3 - Principal Sum / Salary Multiple

War Risk

Is War Risk coverage desired?

Yes
No