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Business Travel and Business/Pleasure Travel Insurance
Coverage Quotation Request Form
Please give us the following details, so we can return a quote.
Name of Company or Organization________________________________________________________
Street Address________________________________________________________________________
City___________________________________State/Zip______________
Phone ( )____________________________________________________
Does the Company/Organization currently hold a voluntary accident insurance program?
Yes No
If Yes, please attach a copy of the most recent policy, certificate or brochure.
Premium and Loss Details for Three Previous Years
Policy
Year |
Number of Insureds |
Total Premium |
Total Incurred Claims |
| 2003 |
$ |
$ |
$ |
| 2002 |
$ |
$ |
$ |
| 2001 |
$ |
$ |
$ |
Description of employees to be covered by class or job description
| Class or Job Description |
Principal
Sum Requested |
| I |
$ |
| II |
$ |
| III |
$ |
| IV |
$ |
List, by class or job description, the coverage you seek
For multiple classes, print multiple copies of this form, completing this section for each class.
Class____
Number of employees in the class__________
Number of employees over age 70 in the class_________
Business Travel Only
Number of employees who travel 50 or more days per year______________
Total Number of travel days for all other employees________________
Business Only Yes No
24-hour Business and Pleasure Yes No
Please describe any other type of coverage desired
Please describe any other type of benefits desired
Are any of your employees subject to hazardous exposure while on business trips, such as might occur with construction eigineers? Yes No
If Yes, please attach details.
Are there occasions when 10 or more employees fly together in an aircraft? Yes No
If Yes, please attach details
Are employees to be insured in company-owned, operated or leased aircraft? Yes No
If coverage is desired for persons flying in company-owned, operated or leased aircraft, please attach these details:
- Make, model, license number, number of passenger seats, number of crew seats
- Name, age, job title and flying time, includig accidents or violations, for each pilot
- Is coverage desired for the crew? Yes No
Responding To Your Request
Please give us your name, title and contact details. If you are an agency, please include contact details on your fax cover sheet.
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