Applicant Information - Chubb in the US



Chubb International Advantage? ApplicationPackage PolicyApplicant InformationNamed Insured FORMTEXT ?????Address FORMTEXT ?????Contact Name FORMTEXT ?????Email Address FORMTEXT ?????Business Website FORMTEXT ?????Expiration DatesRequested Quote Date FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Broker InformationBrokerage Name FORMTEXT ?????Address FORMTEXT ?????Contact Name FORMTEXT ?????PhoneFax FORMTEXT ????? FORMTEXT ?????Email Address FORMTEXT ?????Have you been appointerd with Chubb? FORMCHECKBOX Yes FORMCHECKBOX NoDesired Billing type FORMCHECKBOX Producer FORMCHECKBOX DirectGeneral Information Description of Business Operations (include product descriptions and details of foreign activities, etc.): FORMTEXT ?????SIC Code (if known): FORMTEXT ?????Past loss history (describe insured & uninsured foreign lossesincluding losses from local foreign policies that occurred during past 5 years): FORMTEXT ?????Any Discontinued or Sold Foreign Operations: FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, Explain: FORMTEXT ?????Any bankruptcies in last 5 years: FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, Explain: FORMTEXT ?????Any policy cancelled or non-renewed during past 3 yrs: FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, Explain: FORMTEXT ?????Foreign General Liability FORMCHECKBOX (Per Occurrence limit): FORMTEXT ????? FORMCHECKBOX Standard $1,000,000 Per Occurrence: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Total Estimated Foreign Sales/Revenue:$ FORMTEXT ?????Total Estimated Foreign Contract Cost:$ FORMTEXT ?????Total Estimated Domestic Sales/Revenue:$ FORMTEXT ?????# of Leased /Owned Foreign Premises:$ FORMTEXT ?????Domestic GL Carrier:$ FORMTEXT ?????Intgernational Carrier:$ FORMTEXT ?????Domestic Products Rate:$ FORMTEXT ?????International Premium:$ FORMTEXT ?????List and describe any physical operation overseas such as sales offices, manufacturing facilities, distribution centers, warehouses, etc (including country): FORMTEXT ?????Foreign Business Auto Coverage FORMCHECKBOX (Excess/DIC only): FORMTEXT ????? FORMCHECKBOX Standard $1,000,000 Limit Per Accident: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????# of Foreign Rentals: FORMTEXT ?????# of Foreign Owned Autos: FORMTEXT ?????# of Foreign Non-Owned Autos: FORMTEXT ?????Provide a Description of Owned Autos if Other than Private Passenger type: FORMTEXT ?????Employers Responsibility: (Foreign Voluntary Compensation, Executive Assistance Services, and Contingent Employers Liability) FORMCHECKBOX Contingent Employers Liability: FORMTEXT ????? FORMCHECKBOX Standard $1,000,000 Limit: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Maximum # of employees flying on same flight: FORMTEXT ?????Any flight on non-commercial aircraft (charter, corporate, helicopter)? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, Explain: FORMTEXT ?????Maximum # of employees working at the same location: FORMTEXT ?????Maximum # of employees staying at the same hotel: FORMTEXT ?????Trip Travel Information# TripsTotal # of Employees per TripList Countries of TravelType of Employee (CADN/USN, TCN, or LN)Job Function (Sales, Technicians, etc)Average Duration of Trip(s)If CADN/USN, list Province/State of Hire; If TCN or LN, List Country of Origin FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Permanent Employee InformationCountryJob Function (Sales, Mfg, etc.)Type (TCN, LN, Expat)AnnualPayroll# ofEmployeesIf CADN/USN, list Province/State of Hire; If TCN or LN, list Country of Origin FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Domestic Workers Compensation Experience Modifier: FORMTEXT ?????Foreign Accidental Death & Dismemberment and Medical Expense Coverage FORMCHECKBOX $50,000 AD&D Automatic Limit Provided FORMTEXT ????? FORMCHECKBOX 100,000 AD&D FORMCHECKBOX $250,000 AD&D FORMCHECKBOX $10,000 Medical Expense FORMCHECKBOX $25,000 Medical ExpenseIs coverage desired for Accompanying Spouses? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX $50,000 AD&D FORMCHECKBOX $10,000 Medical Expense FORMCHECKBOX $25,000 Medical Expense# of Spouse(s) FORMTEXT ?????# of Trips FORMTEXT ?????Is coverage desired for Accompanying Children? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX $25,000 AD&D FORMCHECKBOX $10,000 Medical Expense FORMCHECKBOX $25,000 Medical Expense# of Child(ren) FORMTEXT ?????# of Trips FORMTEXT ?????Kidnap and Extortion Coverage FORMCHECKBOX $250,000 Automatic Limit Provided (with High Hazard Country Exclusions) FORMTEXT ?????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 it is agreed that the information supplied in this form shall be the basis of the contract should a policy be issued.Signature of Insured’s Representative:Signature of Producer:Date:Date: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download