Crew Cover Application 011421 Page 2 of 2 aliverisk.com
SECTION III. COVERAGE
1. What is your Gross Revenue for the next 12 months?
2. Do you need to add a specific additional insured to your policy (Blanket AI is automatically included)? Yes No
Written contract needs to be in place to add an additional insured
3. Business Name:
Type: Email Address:
Address:
Reference Number:
4. Do you need a Waiver of Subrogation? Yes No
Business Name:
Type: Email Address:
Address:
Reference Number:
5. Do you have jobs which require you to travel internationally? Yes No
6. How many days do you plan to work outside of the U.S.?
7. Name the cities that you will visit:
8. Do you need worldwide coverage specifically to General Liability? Yes No
9. Are you interested in Hired and Non-Owned Auto Insurance? Yes No
10. Are you interested in Hired and Non-Owned Physical Damage Insurance? Yes No
11. Are you interested in Excess limits? Yes No
If yes, please advise limits needed:
The undersigned declares that to the best of his/her knowledge the statements herein are true. Signing of this Application does not bind
the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be
issued, and this Application will be attached and become a part of such Policy, if issued. Underwriters hereby are authorized to make any
investigation and inquiry in connection with this Application as they may deem necessary.
It is warranted that the particulars and statements contained in the Application for the proposed Policy and any materials submitted
herewith (which shall be retained on files by Underwriters and which shall be deemed attached hereto, as if physically attached hereto),
are the basis for the proposed Policy and are to be considered as incorporated into and constituting a part of the proposed Policy.
It is agreed that in the event there is any material change in the answers to the questions contained herein prior to the effective date of the
Policy, the applicant will notify Underwriters and, at the sole discretion of Underwriters, any outstanding quotations may be modified or
withdrawn.
Submitted by: Applicant Signature:
(Agent)
Date: Name:
(Please Print)
Title:
Date:
FOR CHROME ONLY: Save this application to your desktop and email to ESACrewCover@aliverisk.com or submit from Adobe Acrobat Reader
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
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