FAMILY KIDNAP, RANSOM & EXTORTION APPLICATION

(Attach additional sheets when necessary)

1.         Name of Applicant:                                                                                                                           

2.         Address:                                                                                                                                            

3.         Occupation:                                                                                                                                       

4.         Financial Information:  Net Worth $                              Annual Income $                                        

5.         Family members to be covered:

Relationship to                                Home Address if

Name               Age                     Applicant                                Different than Applicant

6.         Do any of the person(s) listed in number (5) above have an individual net worth greater than US $500,000

If so, please list:

	Occupation		Name		Net Worth

7.         Detail of Anticipated travel outside resident country:                                                                         

                _____________________________________________________________________________________________________________________

8.         Describe any previous kidnap, extortion or detention incidents, attempts or threats:                                                                                                                                                                          

9.                  Describe any security or prevention measures taken to protect those persons in number 5 above from an incident to which this coverage applies:                                                                                                          

10.       Limit of Insurance requested:                                                                                                               

THE UNDERSIGNED APPLICANT DECLARES TO THE BEST OF HER/HIS KNOWLEDGE THE

STATEMENTS SET FORTH HEREIN ARE TRUE.

SIGNING OF THE APPLICATION DOES NOT BIND THE UNDERSIGNED OR US, BUT IT IS AGREED

THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED.

Signature:                                                         Printed Name:                                      Date:                         

 Print and fax to (1) 775-655-8502