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Special Contingency (Kidnap and Ransom) Insurance Coverage
Pre-Screening Questionnaire

Instructions: To apply for our Special Contingency (Kidnap and Ransom) Insurance Coverage, please complete the following pre-screening questionnaire. This is not an application but is required in order to get a quote. All required fields in the Applicant Contact Information have bold labels. Return the form to All Aboard Benefits using one of the following methods:

Print and mail it to us at: All Aboard Benefits, 6162 E. Mockingbird Lane #104, Dallas, TX 75214.
Print and fax it to (214) 821-6676.

Income and net worth are factors that influence approval.

I. Applicant Contact Information

First Name:

Middle Name:

Last Name:

Date of Birth (mm/dd/yy):

Citizen of what country?:

Address (number and street):

City:

State (if applicable):

Country:

Zip Code or Country Code:

Email Address:

Telephone Number:

Is the Applicant also to be insured? Yes No

II. List of All Persons to be Insured:

First and Last Name

Date of Birth (mm/dd/yy)

City of Residence

III. List details of anticipated travel outside country of residence:

(please include names, dates, places of travel and reasons)

IV. Please answer the following pertaining to ALL proposed Insureds:

1) Has there ever been any prior kidnapping, extortion, or detention incident?	Yes No
2) Has there ever been any threat or attempt at a kidnapping, extortion, or detention?	Yes No
3) Are there any current threats or incidents regarding kidnapping, extortion, or detention?	Yes No
4) Is there any existing coverage at this time, or within the last 12 months?	Yes No
5) Are any of the proposed insureds likely kidnapping prospects because of business, outside interests, or other activities? If yes to any of these, please provide details:	Yes No

V. Please answer the following questions about EACH proposed insured:
(If proposed insured is a dependent of the applicant, please list applicant information below.)

First and Last Name

Employer:
Annual Salary:
Net Worth:

VI. Please indicate the coverage you are seeking:

$1,000,000

$2,000,000

$5,000,000

Other Amount:

I have read the above and declare that to the best of my knowledge and belief the statements are true and complete and that I have not knowingly withheld any information which may be material to Underwriters in their assessment and acceptance of the risk. Signing this form does not bind the Applicant nor the Underwriters to complete the insurance, but it is agreed that this form shall be the basis of the contract should a policy or certificate of insurance be issued.

All Aboard Benefits

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Special Contingency (Kidnap and Ransom) Insurance Coverage Pre-Screening Questionnaire