Corporate Kidnap and Extortion Application

(Attach additional sheets when necessary)

 * = Required
1. Customer *
 3. Business or type of industry:
2. Home Office Address:
 4. Financial Information: (Attach latest annual report, if applicable)

Total Worldwide Revenue $
5. Employee census information:
 Total number of Employees (Worldwide):

OVERSEAS TRAVEL INFORMATION

Destination City/Country
Number of Employees
Frequency/Duration of Trip
Reason for Trip

6. Total Number of Permanent Employees stationed/assigned outside the U.S.:

City/Country
Number of Employees
Number of Directors/Officers
Citizenship
7. Describe any previous kidnap, extortion or detention incidents, attempts or threats:
 8. Describe any security or prevention measures to protect those persons in Question 5 above from an incident to which this coverage applies:
9. Limit of Insurance requested:

THE UNDERSIGNED AUTHORIZED OFFICER OF THE CORPORATION DECLARES TO THE BEST OF HIS/HER KNOWLEDGE THE STATEMENTS SET FORTH HEREIN ARE TRUE.

SIGNING OF THE APPLICATION DOES NOT BIND THE UNDERSIGNED OR US, BUT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED.
Signed: Title:
Printed Name: Date: