K&R – TEST FORM | AHT Insurance

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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/Individual Assets: $ *

Total Assets: $

Kidnap and Ransom Coverage

Is Kidnap and Ransom Coverage needed?

Please complete this section if applying for this coverage.

List locations of all resident employees and the number of employees at each. (More than 6 months, please attach separate page if necessary):

Country

Total #

Country

Total #

Country

Total #

Country

Total #

List anticipated foreign travel by specific country and number of employees (less than 6 months, please attach separate page if necessary):

Specific Country

#of Employees

Specific Country

#of Employees

Specific Country

#of Employees

Specific Country

#of Employees

Has the Applicant or any person(s) to be covered under this policy: Ever been declined, cancelled, or had a policy issued with special conditions by any insurance carrier? (copy)

(Missouri applicants need not reply

Has the Applicant or any person(s) to be covered under this policy: Ever received an actual, attempted or threatened kidnapping, extortion, detention, or hijacking attempt?

Please state any special security precautions or attach details:

Requested limits of insurance for Kidnap and Ransom/Extortion Coverage ($):

Please list Director of Security and/or Risk Management contacts (Please include telephone number):