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Application Form for Hiscox Hcp1
(Kidnap, Extortion, & Detention Insurance)

Name of company:

Head office address:

Head office telephone:

Head office fax:

Contact Email:

Nature of business:

Number of directors, officers and employees:

Total sales:

Please list the locations of all
overseas operations with the approximate
number of employees at each location:

Do any members of staff travel to South America, Africa or the Middle East?
(If so please give details):

Have there been any incidents which would
have given rise to a claim under the policy?
(If so please give details):

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