ACE - Foreign Casualty Application

 * = Required
Customer *

Address
Contact
E-mail *
Phone

Quote Needed By
Broker/Agent

Address
Contact
E-mail
Phone
Fax
Intended Inception
 SS# or Dunn & Bradstreet#
Individual Corporation Subchapter “S” Corporation
Not for Profit Partnership  Joint Venture 
Limited Corporation  Years in Business:

General Information
Description of Foreign Operations:

 List Countries where customer will work/travel, or sell products:
Loss History Past 5 Years:

Does the customer have any foreign subsidiaries?
Yes  No

If yes, please attach a list.
Current international insurance carrier:

Premium: $

 
General Liability: (Choose One)
Foreign Sales: 
Contract Cost:
No. of leased or owned Premises: 
 Domestic GL Rate/Carrier:

Number of foreign trips/purpose:
Administration: (sales/clerical) Standard Limit is $1,000,000.
Any Excess Limits for: Occurrence

Products

Personal/Advertising Injury
Labor: (physical/manual labor)
Contingent Auto:

Number of Foreign Owned Autos:

 Standard Limit is $1,000,000.  
Any Excess Limits:

Employers Responsibility – Indicate trip and/or payroll exposure in charts below:
Number of Trips is calculated as number of employees X trips. (Example: 8 employees taking 3 trips each = 24 trips).

Number of Foreign Trips and Duration:

Trip Purpose Number Duration (Avg. Days)
Administrative (sales, clerical)
Labor (physical/manual labor)

Number and Payroll of Employees Abroad:

Trip Purpose
Number
U.S.
Nationals
Number
Third Country
Nationals
Number

Local
Nationals
Administrative
(sales, clerical)		 $ $ $
Labor (physical/
manual labor)		 $ $ $

Employers Liability: Standard Limit is $1,000,000. Any Excess Limits:

Employee Medical And AD&D:
Medical $10,000 $25,000
AD&D $100,000 $250,000
Number of Employees:
Number of Trips:
Average Length of Stay:
Separate Applications required for:
Kidnap & Extortion Property Defense Base Act
Signed Title Date