Terrorism and Armed Shooter application form"

Terrorism and Armed Assailant Insurance Application Form
- Please provide all requested information.
- The proposer and underwriters are free to choose the law applying to this insurance contract.
- Unless specifically agree to the contrary. This insurance shall be subject to New York law.
- Any enquiry or complaint shoud be addressed in the first instance to your broker.
- Any additional information can be entered in the last page.
Institution Profile
Institution, group, organization or company name to be insured
Contact Name

First NameLast Name
Email
example@example.com
Cellphone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Description of Business

Claims History
Have you suffered any violent acts, threats, attacks or incidents at any of your locations.

YesNo
If yes, please provide further details:
Include brief description, date, location and amount
Policy Details
Do you currently have, or have you at any time had, a general liability policy?

YesNo
Have you ever been declined or accepted under special terms for general liability insurance, or has any insurer ever cancelled or declined to renew your policy?

YesNo

Active Shooter coverage required?

	Proposed effective date	Limit of Liability(USD)	Excess (USD)
Option 1
Option 2
Option 3
Option 4
Option 5

ANY ADDITIONAL/FURTHER INFORMATION:

Your Information
Any personal information you have provided will be dealt with by us in compliance with the revisions of relevant US privacy laws and EU Data Protection Directive (also known as Directive 95/46/EC). We have implemented technology and policies to safeguard you privacy from unauthorised access and improper use and will continue to update these measures as new technology becomes available. For the purpose of providing this insurance and handling of any claims which may arise under it, underwrites may need to transfer certain information which you have provided to outer parties in other countries On the basis that anyone to whom we pass to protects it in the same way we would and in accordance with applicable laws. By ticking the box below you agree that such transfer(S) may be made. If you have any questions bot privacy or this privacy statement or would like to make a complaint in relation to out collecting, processing, or storing of your personal information please contact us at info@avgendirect.com
Declaration
You must read this before ticking the box below.

To the best of my knowledge and belief the information provided in connection with this proposal, whether in my own hand or not, is true and I have not withheld any material facts. I understand that non-disclosure or misrepresentation of a material fact will entitle underwriters to void the insurance.

(N.B - A material fact is one likely to influence acceptance or assessment of this proposal by underwriters. If you are in any doubt as o what constitutes a material fact you should consult your broker.)

I understand that by ticking this box of this proposal does not bind me to complete the underwriters to accept this insurance but agree that, should a contract of insurance be concluded, this proposal and the statements made therein shall form the basis and be incorporated into the contract.
By ticking this box I agree that the declaration statement above is true
Should be Empty:

	Address/Zipcode	Number of Employees	Square Feet of Location
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Terrorism and Armed Assailant Insurance Application Form

Institution Profile

Risk Details

Risk Preparedness

Claims History

Policy Details

Your Information

Declaration