Group Benefits Travel Accident Exposure/Application
| GROUP BENEFITSTRAVEL ACCIDENT EXPOSURE/APPLICATION | |
| Name of Account: | |||
| Nature of Business: | SIC Code: | ||
Travel Exposure: (Please include local travel as well as overseas travel)
| Class Description | Number of Employees in each class | Number who travel 50 or more days per year(annual travelers) | Total number of travel days for employees traveling less than 50 days per year |
Examples of Class Description would be: Class 1 – All Executives of the Policyholder, Class 2 - All Sales Staff of the Policyholder, and Class 3 - All other full-time employees of the Policyholder. You may define the classes to meet your needs. Benefits and Hazard, by Class:Example: $500,000 of Business and Pleasure (B&P) for Class 1 Insureds $250,000 of Business Travel Only (BTO) for Class 2 Insureds $100,000 of Business Travel Only (BTO) for Class 3 Insureds
| Accidental Loss of Life Benefit Amount Requested | Hazard Requested (B&P or BTO) |
*If THE LOSS OF LIFE benefit is a multiple of salary, please provide average salary and highest salary by class. Are any insureds are age 70 or over? No _________ Yes ____________ If yes, please provide name, date of birth, and which class they are in.
If the benefit amount is a multiple of salary, provide annual salary information for each person age 70 or above.
_____ ___________________ ______________ ___________________ Class Name Date of Birth Base Annual Earnings Are there any owned or leased aircraft to be covered? Yes_____ No______ Type of aircraft (Year, Make, Model): Fixed Wing ______ Rotorcraft ______ Number of seats: Passenger:______ Crew: ______Are pilots to be covered? Yes_____ No______If yes, please provide pilot history forms. Are there employees located/living overseas? Yes____ No_____If yes, please complete the following information:
|
COUNTRY |
TOTAL # OF EMPLOYEES | TOTAL # OF TRAVEL DAYS WITHIN THIS COUNTRY | TOTAL # OF TRAVEL DAYS OUTSIDE OF THIS COUNTRY |
Are there employees traveling overseas? If yes, please list the countries traveled to, the number of trips per year, and the number of employees traveling to each country.
|
COUNTRY |
# OF EMPLOYEES TRAVELING TO THIS COUNTRY | TOTAL # OF TRAVEL DAYS |
Does the account currently have Accident Insurance? If so, with whom? _______________________ What is the Loss Experience for the past 3 years? ___________________
|
Agent/Broker Name: |
Date: __________________________________________
Quote due date: ______________________ Coverage effective date: __________________
Please return to: William Ferguson,