Please complete all sections fully and accurately. Return the completed form to your Expat Insurance account manager or email to
info@beachfinancialgroup.com. All information is kept strictly confidential and used solely for underwriting and quoting purposes.
Policyholder Information
Eligibility — Class Descriptions
Please separate employees in different classes for different coverage limits. Example: All Full Time U.S. Managers and Sales Reps, Contractors, Consultants, or Board Members.
For US Employees
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 (e.g., trip to bank, lunch with client, sales call, business conference). It includes local and/or foreign trips.
Item
Class 1
Class 2
Class 3
Average Annual Salary
AD&D Limit ($100,000 / $250,000 / $500,000 / or higher)
Type of Coverage 1) Business + Personal Deviation, or 2) Business + Pleasure (365 days)
Coverage Scope 1) Local and Foreign Coverage, or 2) Foreign Coverage Only
Number of Employees who each Travel 50+ Days per Year
Number of Employees who each Travel 25–49 Days per Year
Number of Employees who each Travel 1–24 Days per Year
Number of Total Employees (including those who don't travel)
For Non-US Employees
Please copy and repeat this table for each additional foreign location, especially for employees in Ukraine, Russia, and Belarus.
Item
Class 1
Class 2
Class 3
Average Annual Salary
AD&D Limit ($100,000 / $250,000 / $500,000 / or higher)
Type of Coverage 1) Business + Personal Deviation, or 2) Business + Pleasure (365 days)
Coverage Scope 1) Local and Foreign Coverage, or 2) Foreign Coverage Only
Number of Employees who each Travel 50+ Days per Year
Number of Employees who each Travel 25–49 Days per Year
Number of Employees who each Travel 1–24 Days per Year
Number of Total Employees (including those who don't travel)
Known Concentration of Risk
Incentive trips, trainings, seminars, retreats, volunteer activities, etc.
Attendance
Destination (City, Country)
Duration (No. of Days)
How Many Times a Year
Expatriate Employees / Long Term Assignment
Are there any employees on long term assignment exceeding 180 days?
If Yes, please complete the table below.
Class
Age or DOB
Job Title
Annual Salary
Assignment Country
Total Travel Days
Age 70+ Employee Information
Are there any age 70+ employees?
If Yes, please complete the table below even if they don't travel.
Class
Age or DOB
Total Travel Days
Out of Country Travel Exposure
Examples: US Employees traveling abroad, Non-US Employees traveling into US, or Non-US Employees traveling to Non-US locations.
Out of Country Medical Limit
Class
Country of Origin
Destination Country*
Total # of Employees Traveling
Travel Days Per Employee Per Year
*Additional detail is required for employees traveling to: Afghanistan, Belarus, Cuba, Iran, Israel, Lebanon, North Korea, Syria, South Sudan, Crimea Region, Russia, Ukraine, and Venezuela.
War Risk and Security Evacuation Coverage
Is War Risk Coverage needed?
Is Security Evacuation Coverage needed?
If Yes to either above, please complete the table below for all applicable foreign destinations.
Foreign Destination Country (not in-country travel)
Total # Employees Traveling
Avg Travel Days Per Employee/Year
Employees Permitted Entry? (Y/N)
Latest Safety Protocols
Local Authorities Accompany Employee? (Y/N)
Local Authorities Carry Weapons? (Y/N)
Employees Carry Weapons? (Y/N)
Afghanistan
Algeria
Armenia
Azerbaijan
Belarus
Burkina Faso
Cameroon
Central African Rep.
Chad
Cuba
Democratic Rep. of Congo
Egypt
Ethiopia
Haiti
India – Assam / Bihar
India – Jammu & Kashmir
Iran
Iraq
Israel (All other regions)
Israel (Gaza / West Bank)
Lebanon
Libya
Mali
Mauritania
Moldova
Morocco – Western Sahara
Mozambique
Myanmar
Niger
Nigeria
North Korea
Pakistan
Philippines
Russia
Russia – North Caucasus
Russia – Crimean Region
Somalia
South Sudan
Sudan
Syria
Tajikistan
Thailand (Pattani, Yala, Songkhala & Narathiwat)
Ukraine (Non-Crimea)
Venezuela
Yemen
Company Aircraft Information
Are there any owned or leased aircraft to be covered?
If Yes, please complete the table below.
Year
Make
Model
Serial Number
Max Passenger Capacity
Avg Passenger Capacity
Crew Capacity
Avg Usage (hrs/yr)
Is piloting coverage to be provided?
Unusual or Hazardous Exposures
Are there any unusual or hazardous exposures to be covered?
Detail:
Are there any employees whose job duties take place in moving vehicles, such as ferries or trucks?
Detail:
Are there any employees whose occupational duties regularly take place off-site, such as excavation, construction, or field work?
Detail:
Prior Coverage
Has the company had prior Business Travel Accident coverage?
Authorization & Signature
By signing below, the authorized representative certifies that all information provided is accurate and complete to the best of their knowledge,
and authorizes Expat Insurance / Beach Financial Group to use this information for the purpose of obtaining insurance quotes on behalf of the company.
