Name
Phone







6650 Reseda Blvd
Suite #108
Reseda, CA 91335

contact@gisinsure.com
Kidnap & Ransom Insurance
 

First Name:
Last Name:
Business Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Who Referred You To Our Site?

Underwriting Information
 

Date of Birth (mm/dd/yy):

 

Height (ft - inch):
Weight (lbs):
Estimated Annual Income:
Estimated Net Worth:
Citizen of what Country:
Passport Number:
Indicate in which Countries you will want the Coverage Effective In:
Estimated Date you want the Coverage Effective:
Please Describe Your Business, Occupation, Details and Reason for the Travel:
Please Indicate The Most Recent Countries You Have Traveled To:
Please List The Person(s), Age, Relationship & Occupation For Whom Coverage Will be Secured, If Other Than The Individual Named Above:  

 

Miscellaneous Information
 

Describe Any Recent Threats, Extortion Attempts:

 

Current Insurance Company:
A Normal Policy Period is One Year. Would this be OK? yes no  
If Not, Indicate the Policy Period You Want: 

Coverage Information
 

Ransom Money Coverage Limits Requested:

 

Detention Money Coverage Limits Requested:
Reward Money Coverage Limits Requested:
Additional Expenses Money Coverage Limits Requested:
Life Insurance (Accidental Only) Coverage Limits Requested:
Accidental Permanent Total Disability Coverage Limits Requested:
Questions or Comments
to help the Agent: