Welcome to The Allen J. Flood Companies, Inc. :: Quotations/ Underwriting Forms

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	Request For Policy Issue Form

All Fields with (*) are Required

Submission Date *

(mm/dd/yyyy)

Quote Due Date *

(mm/dd/yyyy)

RISK INFORMATION

First Name *

Last Name *

Street Address *

City *

County *

State *

Zip Code *

Telephone Number *

Fax Number

Nature of Business *

Standard Industrial Classification (SIC) *

Total Number of Employees *

Total Number of Employees to Be Covered *

Name of individual completing this form.

First Name *

Last Name *

Telephone number of individual completing this form. *

E-mail address of individual completing this form. *

Please indicate (below) the Class Description, Principal Sum, Type of Coverage, and The Total Number of Employees Who Travel on business for each classification. Also, please indicate the Number of Truck Drivers and Helpers, and Indicate Long - or Short-Haul Trucking.

Please Note: A travel day is any day or part of a day that the Insured Person is away from his or her regular place of business on the business of the policyholder; for example, trip to bank, lunch with client, sales call, etc.

	Class 1	Class 2	Class 3	Class 4
Class Description
Principal Sum
Type of Coverage (Business Only or Business & Pleasure)
Over 50 Travel Days/Year
26 to 50 Travel Days/Year
11 to 25 Travel Days/Year
1 to 10 Travel Days/Year
No Travel
Number of Company Cars
Number of Truck Drivers and Helpers
Indicate Long- or Short-Haul Trucking

SALARY

Is salary used to determine Principal Sum? *

Yes No

If Yes, define "salary" and complete chart below

Indicate Average Salary and Highest Salary for each Class. (For Principal Sum amounts over $500,000, please attach a separate listing of salaries by Class.)

Class	Average Salary	Highest Salary

Please Note: The Standard Age Reduction Schedule will apply. This reduces benefits applicable to employees over age 69. Please attach a list of individuals over age 69 (including Class and date of birth) only if Full Benefits for those employees over age 69 are to be maintained.

FOREIGN EMPLOYEES

Are foreign employees to be covered? *

Yes No

(If Yes, list Name of Country, Number of Employees and Class.)

Name of Country	Number of Employees	Class

BENEFITS

Accidental Death Only	Accidental Death & Dismemberment
Additional Benefits (Describe)

AGGREGATE LIMIT

What Aggregate Limit of Indemnity is required?

Per Accident Per Aircraft Accident

COMPANY AIRCRAFT INFORMATION

Does the company (or any subsidiary/division) own, lease or operate any aircraft? *

Yes No If Yes, complete the chart below.

Year	Make	Model	Serial Number	Seating Capacity		Average Usage
Year	Make	Model	Serial Number	Passenger	Crew	Average Usage

Please note any other appropriate details about aircraft:

Is piloting coverage to be provided? *

Yes No

If Yes, is piloting coverage for company aircraft only? *

Yes No

UNUSUAL OR HAZARDOUS EXPOSURES

Are there any known concentrations, unusual or hazardous exposures to be covered? *

Yes No

Are there any employees whose job duties take place in moving vehicles? Examples include but are not limited to tug boats, ferries, other water carriers, and trucks. *

Yes No

Are there any employees whose occupational duties regularly take place off-site? Examples include but are not limited to field electric work, construction, and excavation. *

Yes No

If you have responded Yes to any of these questions, please describe:

PRIOR COVERAGE

Insurance Company Name:

Effective Date:(mm/dd/yyyy)

Renewal Date:(mm/dd/yyyy)

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