Kidnap and Ransom Insurance Quote Request Fields that are BOLD must be filled CLIENT INFORMATION First: Last Name: Middle: Phone: Email: DOB: Address: City State: Country: Zip Code: Citizen of what country?: Annual Income: Value of Personal Assets: Business or Occupation: Name of Company: Address: City State: Country: Zip Code: ADDITIONAL APPLICANTS INFORMATION Please list all other persons to be insured Name: DOB: City of Residence: Name: DOB: City of Residence: Name: DOB: City of Residence: ADDITIONAL INFORMATION To be answered for ALL proposed insureds List details of anticipated travel outside country of residence (please include names, dates, places of travel and reasons): Has there been any prior kidnapping, extortion, or detention incident? Yes   No Has there ever been any threat or attempt at a kidnapping, extrotion, or detention? Yes   No Are there any current threats or incidents regarding kidnapping, extortion, or detention? Yes   No Is there any existing coverage at this time, or within the past 12 months? Yes   No Are any of the proposed insureds likely kidnapping prospects because of business, outside interests or other activities? Yes   No If yes to any of these, please provide details Please indicate the coverage you are seeking: $1,000,000   $2,000,000 $5,000,000   Other:

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