Form Application for International Package

Application for International Package

Producer:

Contact:

Telephone:

Fax:

Address line 1:

Street:

City, State:

Zip Code:

Address line 2:

Street:

City, State:

Zip Code:

Insured's Name (as it would appear on the policy):

Insured's Address line 1:

Street:

City, State:

Zip Code:

Insured's Address line 2:

Street:

City, State:

Zip Code:


Desired effective date:


Foreign General Liability

Limits:

Please describe products/services or other overseas activities of the client. Identify class of business (Send brochures).



a. Total domestic sales (US $).

b. Domestic General Liability rate.

c. Total foreign sales/revenues prior year (US $).

d. Estimated foreign sales/revenues coming year (US $).


Destination of products/services or other overseas activities.

Please describe any losses sustained within the last five years.


Foreign Auto Liability:

Limits:

Number of permanent owned autos:

Estimated # of autos rented overseas annually:


Foreign Voluntary Workers Compensation/Employers Liability/Repatriation

Limits:


Estimated # of U.S./Canadian employees or 3rd Country Nationals employees traveling abroad.

To which countries are they traveling?



Job description of traveling employees (i.e. salesmen, exec.).



Estimated Number and average duration of trips overseas.



Number of U.S./Canadian citizens employed full-time overseas.

Job Descriptions:

Payroll:


Number of Foreign Nationals employed full-time by country:

Job Descriptions:

Payroll:

Foreign Commercial Property */ Premises Liability:

Type of Property:

If "Other", selected, please describe here


Location(s) of Property / Premises Insured (include complete address):

Location 1 Address line 1:

Street:

City, State:

Zip Code:

Location 1 Address line 2:

Street:

City, State:

Zip Code:


Estimated property value of Building:

Estimated property value of Contents:

Estimated property value of Bus. Income:

Construction:

Occupancy:

Protection (Fire & Theft):

Surrounding Exposures:

Location 2 Address line 1:

Street:

City, State:

Zip Code:

Location 2 Address line 2:

Street:

City, State:

Zip Code:

Estimated property value of Building:

Estimated property value of Contents:

Estimated property value of Bus. Income:

Construction:

Occupancy:

Protection: (Fire & Theft):

Surrounding Exposures:


Please describe any property losses sustained within the last five years.



Ocean Marine Cargo:

Cargo values in this section are equal to the amount of invoice, including charges, plus ocean freight plus 10% unless otherwise noted:

Cargo Values insured for last 12 months:

Via Ocean (Under Deck):

Via Air:


Estimated Cargo Values to be shipped during policy period (Annually):

Via Ocean (Under Deck):

Via Air:


Limit of cargo insurance any one place, any one time by any one vessel:

Via Ocean (Under Deck):

Via Air:


Briefly describe the number and nature of losses:





Please describe overseas packing and use of intermodal containers:





Please specify any charter arrangements, contractual waivers or reductions in carrier liability: on deck shipments pursuant to an On Deck Bill of Lading; or other potential recovery reducing agreements:


Please specify anticipated shipment values per country:

Number Country of Destination Via Ocean Via Air
1
2
3
4
5

Please attach schedule if applicant exports to more than 5 countries.




Corporate Kidnap and Ransom/Extortion

(Includes U.S. and Foreign incidents)

Limits: $1,000,000 per occurrence

Persons for whom insurance is desired; please provide a complete employee census:

Number Resident Country Name Title
1
2
3

Please attach separate schedule if necessary or if blanket coverage indicate number of employees to be covered:


Extent of travel outside resident country(ies) by the person(s) in question above:

Number Name and/or Title Destination Frequency of Travel Duration of Travel
1
2
3

Please attach separate schedule if necessary.


Has there ever been a kidnapping or an attempted kidnapping, a hijacking or an attempted hijacking, or any extortion demand(s) (i.e. threat to reveal a trade secret) of any of the Applicant’s directors, officers, employees or their dependents? If yes, please give full particulars:




Foreign Travel Accident and Health:

Accidental Death & Dismemberment
Limits:


Accident and Sickness Medical Expenses
Limits:

Emergency Medical Evacuation Limits: $100,000 per occurrenceRepatriation of Remains Limits: $25,000 per occurrenceAmerican International Assistance Services: 24 hour traveler assistance hotline


Number of US employees that travel overseas annually:

Estimated Number of trips abroad annually:

Average duration of trips abroad:


Covered Employees Schedule:

Name Spouse Number of Dependent Children (18 yrs. & under)

Please attach a separate schedule if necessary or for blanket coverage indicate class of covered employees (i.e. “all salesmen who travel abroad”; all executives who travel abroad.)



Foreign Comprehensive Dishonesty, Disappearance, Destruction

Limit Options

If "Other":

Are the books audited by an independent CPA? If so, by whom and how often?


If not, describe the limitations:


Are these audits made for each entity to be covered? If not, please explain:


If an independent CPA is not used, who is responsible for auditing the books?


Briefly explain the scope and limitations of such audit:


Does the audit include all locations?


If not, please explain:


Inventory Control, do the employees who reconcile the monthly bank statements also:

a) sign the checks?

b) handle the deposits?

c) have access to check signing machines or signature plates?


Important Note:

It is inadvisable for the reconciliation to be done by an employee who also signs checks, handles deposits or who has access to check signing machines or signature plates because under such circumstances losses may be concealed. If the answer to any question in this section is yes, will you correct this weakness? Yes

Computer Control

Are programmers and operators rotated periodically to minimize the possibility of machines being used improperly?

Are computerized check writing operations segregated from departments that authorize checks?

Securities

State the value of negotiable securities owned or held abroad:

Where are the securities kept?

Precious Metals

Is there an exposure of precious metals or stones?

Classification of employees:

"A" = All Officers;
"B" = All employees that handle, have custody, or maintain records, securities or other property?;
"C" = All other employees
Headquarters Number of "A" Employees Number of "B" Employees Number of "C" Employees



Political Risk:

(Coverage for acts of seizure of covered property by a foreign government or acts of embargo by the U.S. Government)

Please estimate the maximum exposure (values) expected in each country over the next twelve months for the three perils below.

Country Expropriation of Inventory & Equipment Expropriation of Equity Embargo

Please select Limits of Liability as follows:

($25,000, $50,000, $100,000, $250,000, $500,000)

Expropriation of Inventory and Equipment ($ per occurrence):

Expropriation of Equity ($ per occurrence):

Embargo ($ per occurrence):

Country Aggregate Limits (must be equal to or as large as largest of per occurrence limits)

Expropriation of Inventory and Equipment ($ per occurrence):

Expropriation of Equity ($ per occurrence):

Embargo ($ per occurrence):

Policy Aggregate Limit (choose as above, or $1,000,000)

Have there ever been any material disputes between the applicant and the government of any country in which the applicant has Covered Property? If so, please indicate the number of disputes and describe each, using additional pages if necessary:



For equity investments, please list the countries and briefly describe the operation(s) of the foreign enterprise:



The undersigned applicant declares that to the best of his knowledge the statements set forth in this questionnaire are true and no other material information has been withheld. The undersigned also agrees that the existence of any policy that may be issued will not be disclosed to the host government. Signing of this questionnaire does not bind the undersigned to complete the insurance, but it is agreed that this form shall be the basis of insurance should a policy be issued, and this form will be attached to and form a part of the policy.

Notice to New York applicants: Any person who knowingly and with intent to defraud any insurance company or other persons files an application for insurance containing false information or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Signed for Applicant Company:

Title:

Date:

Producer Name/Contact:

Title:

Date: