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Crime + CSP
General Company Info
Name of Applicant
*
Website
*
Physical Address
*
State or County of Incorporation
*
Years in Operation
*
Nature/Description of Operations
*
WhatsApp Phone Number
*
Telegram Handle
Are you working with an insurance broker?
*
Are you working with an insurance broker?
Yes
No
Claims History
Has any claim/legal proceeding been brought against the Applicant?
*
Has any claim/legal proceeding been brought against the Applicant?
Yes
No
Is the Applicant aware of any facts/circumstances that might give rise to a claim?
*
Is the Applicant aware of any facts/circumstances that might give rise to a claim?
Yes
No
Has any director/officer been charged in a civil or criminal proceeding (e.g., harassment, discrimination)?
*
Has any director/officer been charged in a civil or criminal proceeding (e.g., harassment, discrimination)?
Yes
No
Prior Insurance Coverage
Current Insurer
*
Expiration Date
*
Current Premium
*
Are the Limits and Retentions noted above the same as the Applicant’s current coverage?
*
Are the Limits and Retentions noted above the same as the Applicant’s current coverage?
Yes
No
Limit of Liability
*
Retention
*
Premium
*
Expiration Date
*
Representations and Notice
Certification of Truthfulness
*
Certification of Truthfulness
I certify that the information provided is true and complete.
I agree to notify the insurer of any changes before the policy becomes effective.
I understand this application does not obligate the insurer to issue a policy.
Signature
*
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