Business Travel Accident Questionnaire 011521 Page 3 of 3 aliverisk.com
WAR RISK COVERAGE
Is War Risk Coverage* desired? Yes No
If yes, please complete the chart below.
*War or act of war is a standard exclusion on Travel Accident policies. In order to have coverage for losses resulting from war or acts
of war, War Risk Coverage must be purchased.
PRODUCER INFORMATION
Producer Name: __________________________________________________________ Producer Code: _____________________
Contact Person: ______________________________________________________________________________________________
Address: ________________________________________________ City: __________________ State: _____ Zip Code: ________
Phone: __________________________________________________ Fax: ______________________________________________
E-mail Address: ___________________________________________ Web Address: ______________________________________
Requested Commissions: ___________________________________________ Broker of Record? Yes No
Are you a licensed Accident & Health Producer in the applicable risk state? Yes No
State License Number: _______________________________________ National License Number: __________________________
Alive Risk is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a subsidiary of Ryan Specialty Group, LLC
(RSG). Alive Risk works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the public. Some products may only be available in certain states, and some products may
only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC (License # 0G97516). ©2021 Ryan Specialty Group, LLC
