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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
Has any claim/legal proceeding been brought against the Applicant?
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
Is the Applicant aware of any facts/circumstances that might give rise to a claim?
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
Has any director/officer been charged in a civil or criminal proceeding (e.g., harassment, discrimination)?
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
Are the Limits and Retentions noted above the same as the Applicant’s current coverage?
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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