Fillable Business Travel Accident Application36-10802

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Business Travel Accident Application36-10802

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The Business Travel Accident Application36-10802 form is 2 pages long and contains:

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REQUEST FOR QUOTE – BUSINESS TRAVEL ACCIDENT
Submission Date:
Quote Due Date:
Requested Effective Date:
RISK INFORMATION
Name of Organization:
Street Address:
City:
State:
Zip Code:
1.
Do you current have Business Travel Accident coverage?
Yes
No
If yes, please provide a copy of your policy’s schedule page.
TRAVEL ASSESSMENT
1.
Please complete the chart below based on your current coverage. If changes are desired, please indicate where
applicable. Attach a separate sheet of paper if additional room is needed.
Class 1
Class 2
Class 3
Class 4
Class Description: (i.e. Managers, Sales, All
Employees
Benefit Amount**
Type of Coverage (Business Travel Only, Business and
Pleasure or Full Occupational)
Total Number of Insureds:
Number of Insureds Who Travel on Business:
Over 50 days per year*
26 – 50 days per year*
10 – 25 days per year*
1 – 9 days per year*
0 days per year*
# of Truck Drivers, Chauffeurs, and / or Deliverymen
Number of Company Cars
Average Salary of Travelers
*Any time away from the office (business lunches, client visits, etc.) is considered a day of travel.
**If salary is used to determine the benefit for a Class, please attach a salary census for all the insureds in that Class.
AFFILIATED COMPANIES / SUBSIDIARIES
1. List affiliated companies / subsidiaries to be included under this program and their nature of business. Remember
to include the affiliated companies’ travel exposure in the travel assessment above.
COMPANY AIRCRAFT
1.
Does your company own, operate, or lease any aircraft? If yes, complete the chart below.
Yes
No
Year
Make & Model
FAA or Serial #
Crew Seats
Passenger
Seats
Avg.
Occupancy
Avg. Usage
Business Travel Accident Application
Page 1 of 2
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
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2.
Do you wish to cover employee pilots? If yes, please list their names and their respective type of
pilot license.
Yes
No
70 AND OVER EMPLOYEES
1.
Are there any employees age 70 or greater that are to receive full benefits?
Yes
No
a.
If yes, please complete chart below.
b.
If no, our standard benefit reduction will apply. This schedule reduces benefits applicable to
employees age 70 or greater.
Date of Birth
Class Number
WAR RISK COVERAGE:
1.
Is War Risk* coverage desired? If yes, please complete chart below.
Yes
No
Visited Country
Length of Stay
Average Number of Trips
*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.
ACKNOWLEDGEMENTS AND SIGNATURES
a.
Fraud Warning
It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
b.
Applicant’s Acknowledgement I, the Applicant, declare, to the best of my knowledge and belief, that all
statements and answers in this application are true and complete. I understand and agree that (a) this application
will form part of any policy issued, (b) no information given to or acquired by any representative of Philadelphia
Indemnity Insurance Company will bind it, unless it is in writing on this application, (c) no waiver or modification will
bind the Company unless it is in writing and is signed by an executive office of Philadelphia Indemnity Insurance
Company and (d) only those persons eligible under the terms of an issued policy will be insured.
Signed:_________________________________________
Title:
Date:
Agent Name:
Agency:
Address:
City:
State:
Zip:
Email:
Phone:
Fax:
Are you a licensed A&H Producer in the applicable risk state?
Yes
No
Please return form to:
The Allen J. Flood Companies, 2 Madison Avenue, Larchmont, NY 10538
info@ajfusa.com ● Phone: 1-800-734-9326
Business Travel Accident Application
Page 2 of 2
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
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Completed 2 July 2020

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