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Application Form for Family Kidnap & Extortion

Name of applicant:
Address of applicant:
Telephone of applicant:
Applicant's Fax:
Applicant's Email:
Applicant's country of birth:
Details of applicant's occupation (s):
Please list all the names and city of residence of the people to be insured:
Have there been any kidnaps, attempted kidnaps or threatened kidnaps? (If so please give brief details):
Please give brief details of any travel plans outside the country of residence of all people to be insured:
Does the applicant's net assets exceed:
     (i)   US$ 500,000          Yes   No
     (ii)  US$ 1,000,000       Yes   No
     (iii) US$ 2,500,000       Yes   No
     (iv) US$ 5,000,000       Yes   No
     (v)  US$ 10,000,000     Yes   No
Limits of liability requested:

I have read the above and declare that to the best of my knowledge and belief the statements are true and complete.

Submiting this form does not bind the Applicant to complete the insurance but it is agreed that this form shall be the basis of the contract should a policy be issued.


Mailing Address: P.O. Box 284, 15476 NW 76 Ct - Miami Lakes, FL 33016
Tel: (305) 556-1488  Fax: (305) 556-3680