PropertyCrimeMarine

Foreign Property

(A complete Schedule of Values must be attached for all foreign locations. For all locations with Total Insured Values > $500,000, the following COPE data is required)

Complete address of overseas location:

Construction class of building, age, number of floors:

Occupancy (office, manufacturing, warehouse, etc. If manufacturing, please describe the process - how products are made, assembled, or fabricated):

Protection at location (sprinklers, distance from nearest paid fire dept., are there fire and/or burglar alarms and are they connected to central station monitoring, 24-7 guard service, public hydrants within 50 meters; if manufacturing, how are flammable chemicals and solvents stored?):

Exposures (occupancies of nearest neighbors within 100 feet; any rivers, lakes or other natural bodies of water within 1 mile, etc.):

Values:

Building (Real Property):

Total Business Personal Property (contents, stock, EDP):

Business Income/Extra Expense:

Ocean Marine Cargo Coverage

Maximum Limit per shipment:

Describe Property/Commodity Shipped:

Estimated # of Shipments per year:

Are Certificates required?

Yes

(If certificates are required, we will refer this application to our Ocean Cargo Department for a standalone policy.)

Subject to On Deck Bill of Lading?

Yes

Foreign Crime Coverage (for foreign physical locations)

Select desired limits:

Employee theft:

$5,000

$10,000

$25,000

Forgery or Alteration:

Employee theft:

$2,500

$5,000

$10,000

$25,000

Money Orders and Counterfeit Currency:

Outside Premises:

$5,000

$10,000

Underwriting Information - the following is required when there are foreign locations and employees:

Sign Checks:

Yes

Handle deposits:

Yes

Have access to Check signing machines or signature plates

Yes

Securities Control:

Are negotiable securities or money kept on premises?

Yes

If yes, please provide value kept on premises:

Are the books audited by an independent CPA?

Yes

Political Risk Coverage

Confiscation and Selective Discrimination

$50,000

$100,000

$250,000

$500,000

$1,000,000

Other

If other, please provide value here:

Confiscation and Selective Discrimination:

List location(s) (host country) of any investments in foreign enterprises?

Please describe the investment and the foreign enterprise and indicate percent of ownership:

What is the name of the subsidiary or foreign enterprise?

Describe owned inventory or equipment in the host country:

NOTICE TO APPLICANTS: This application is for the purpose of obtaining a quotation and does not bind the applicant or the Company to complete the insurance. The Undersigned declares that to the best of his/her knowledge, the statements set forth herein are true and that no other material information has been withheld. This form shall be the basis of insurance should a policy be issued. If the information supplied herein changes between the date completed and the effective date of the insurance, the undersigned shall notify the Company of the changes and the company reserves the right to modify or withdraw any offer for insurance. All written statements, materials or documents furnished to the Company in conjunction with this application, regardless of whether such documents are attached to the policy, are hereby incorporated by reference into this application and made a part hereof, including without limitation anysupplemental applications or questionnaires

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.