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Kidnap, Ransom & Extortion

* Required

Application Contact Information

Prefix:

* First Name:

* Surname:

* Address 1:

Address 2:

* City:

* State / Province:

* Zip / Postal Code:

* Country:

* Citizenship:

* Country of Residence:

* Telephone:

Fax Number:

* E-mail:

* Date of Birth:

* Gender:

 

Policy Request Information

* Level of Coverage Requested:

* Duration of Policy Requested:

* Policy Effective Date:

* Type of Coverage Requested:

Individual: Yes No
Family: Yes No

 

Exposure / Risk Information

 

Country

Duration

Reason for Travel

1

2

3

4

5

 

Occupation & Employment Information

* Job Title & Duties:

* Employer:

* Income (Salary, Bonuses, Stock Options):

$

* Is your salary public knowledge?

Yes No
If yes, then explain why:

* Length of time in current position:

If retired, date of retirement:

* Employer Address:

* Will the employer pay or reimburse for this coverage?

Yes No

 

Gross / Net Worth

* Estimate of Gross / Net Worth:

$

* Is this public information?

Yes No
Why?

* Estimate Breakdown (Cash, Stocks, Real):

If private stock, then how is it valued?

* Estate, Private Assets

 

Complete the following information if family coverage is requested

How many family members?

1.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Visiting Country

* Duration of Visit

 

 

2.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Visiting Country

* Duration of Visit

 

 

3.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Visiting Country

* Duration of Visit

 

 

4.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Visiting Country

* Duration of Visit

 

 

5.)

* Name

* Date of Birth

* Relationship

* Citizenship

 

* Resident Country

* Visiting Country

* Duration of Visit

 

 
 

Questions

* Why do you want this coverage?

* Has any advisor recommended that you obtain this type of insurance?

Yes No

* Have you been recently briefed on general or specific security issues that directly relate to you or your employer?

* Have you ever been issued this type of insurance?

Yes No

* Have you ever been declined for this type of insurance?

Yes No

* Describe your families' security plan:

* Do you have a current or past threat or incident?

Yes No

   
 
   

PHONE: +1-866-510-0149

International Insurance & Investments LLC

1725 Washington Rd. · Suite 406
Pittsburgh, PA. 15241 USA

International Insurance & Investments LLC is licensed in the European Economic Area, Switzerland, The United Kingdom and the United States of America. In the USA, the firm is licensed in 17 states. In the United Kingdom, the firm is authorized and regulated by the Financial Services Authority # 315054.


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ALL RIGHTS RESERVED.
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