JotForm

DBA Insurance Quote Application

Please Be Sure To Answer All Questions
Applicant Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Contact Name (must be an officer, owner or partner)

First Name Last Name
Contact Phone Number

- Area Code Phone Number
Contact Email
Proposed Effective Date
Organization Type

Corp LLC Partnership Individual Other
Number of Years in Business
Number of Years Experience Outside of the U.S.
Any previous DBA-related contracts or work?

Yes No
Contract Type

Dept of Defense Dept of State/U.S. AID US Army Corp of Engineers/JCC Other
Are you the prime contractor?

Yes No
If no, name of prime contractor
Have you obtained a written waiver from the Dept of Labor for Third Country Nationals or Local Country Nationals?

Yes No N/A
If yes to above, please explain
Please provide a description of operations on all contracts to be covered including but not limited to duration of the contract, whether a new bid or renewal of an existing contract, estimated contract value, countries where work will be performed, and contract number (if you are a subcontractor, please provide the subcontract number)
Do you perform work underground or over 15 feet?

Yes No
If yes, please describe
Are employees tenured employees of the company?

Yes No
Are subcontractors used?

Yes No
If yes, what percent of work is subcontracted?
If yes, do you require a certificate of DBA coverage from the sub contractor?

Yes No
Who Is Security Provided By?

Employees Outside Contractors U.S. Military
If provided by outside contractor, please advise contractor's name
Do employees carry firearms?

Yes No
If yes, are they trained to carry firearms?

Yes No
Are employee background checks conducted?

Yes No
Are personnel records (passports, visas, etc) maintained by your HR dept?

Yes No Option 3
if yes, please state the location of these records
Are physicals required after offers of employment are made?

Yes No
Are physicals required prior to work release?

Yes No
Are employees processed through CRC?

Yes No
Do employees undergo psychiatric pre-screening prior to deployment to hostile zones?

Yes No
Do you have a documented evacuation plan for your employees in the event of emergency medical situations?

Yes No
Do you have a documented evacuation plan for your employees in the event of political instability?

Yes No
If yes, please describe
Are medical facilities available at or near the worksite(s)?

Yes No
If yes, please describe
Do you provide non-work related medical insurance including evacuation coverage for non-work related medical emergencies for your U.S. Nationals?

Yes No
Do you provide this coverage for your Third Party Nationals?

Yes No N/A
Do you provide this coverage for your Local Nationals?

Yes No N/A
Remuneration/Employee Info
Country of Duty
Job Classification/Duties
Annual remuneration for US Nationals (USNs)
Number of US Nationals (USNs)
Annual remuneration for Third Country Nationals (TCNs)
Number of Third Country Nationals (TCNs)
Annual remuneration for Local Country Nationals (LCNs)
For any employees not included in the above section, please provide the following
Country where working
City, State or Military Base
Job Classifications/Duties
DBA Worksite Location
Number of persons traveling
Average number of weeks traveled per person
Transportation Info - US Nationals
Maximum number traveling together on land (auto/bus)
Maximum number traveling together over water
Maximum number at the same worksite sleeping quarters
Transpoprtation Info - Third Country Nationals
Maximum number traveling together on land (auto/bus)
Maximum number traveling together over water
Maximum number at the same worksite sleeping quarters
Transportation Info - Local Country Nationals
Maximum number traveling together on land (auto/bus)
Maximum number traveling together over water
Maximum number at the same worksite sleeping quarters
Loss History
In the past 5 years, have you had any DBA-specific losses?

Yes No
If yes, please provide a detailed description. Please also provide a loss run from any DBA carrier(s) you have been insured with during the past 5 years
Should be Empty:

DBA Insurance Quote Application

Remuneration/Employee Info

For any employees not included in the above section, please provide the following

Transportation Info - US Nationals

Transpoprtation Info - Third Country Nationals

Transportation Info - Local Country Nationals

Loss History