Portland Defense Base Act DBA Application Form

Defense Base Act Insurance Application

Applicant Information
Applicant:*
Contact:*
Applicant Website:
Applicant Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Producer Information
Producer Name:*
Producer Agency Name:*
Producer eMail Address:*
Producer Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Coverage Information
Proposed Effective Date:
Date Format: MM slash DD slash YYYY
Proposed Expiration Date:
Date Format: MM slash DD slash YYYY
Entity Type:
Years in Business:
Prior DBA Coverage?
- Yes
- No
Type of Contract:
If Other, Please Describe:
Is Applicant Primary Contractor?
- Yes
- No
If No, Indicate Primary Contractor:
Did applicant obtain a written waiver from the Department of Labor for Non-US employees?
- Yes
- No
If Yes, Please Attach
Drop files here or
Are Subcontractors Used?
- Yes
- No
If Yes, for What Percentage of Contract Are Subs Used?
Are Subcontractors Required to Obtain Their Own DBA?
- Yes
- No
Are DBA Certificates Obtained?
- Yes
- No
Please describe contract in as much detail as possible (Scope of work, length of time, is this a bid or has contract already been awarded, contract number, etc.):
Employees: US Nationals, 3rd Country Nationals, Local Nationals
Job Classification US Payroll US # 3rd Country Payroll 3rd Country # Local Payroll Local #

List Column Totals in Final Row. Press the "+" button to add a row.
Employees: US Nationals, 3rd Country Nationals, Local Nationals
Site Location Country Site Location City/Base # of US # of 3rd Country # of Local

Press the "+" button to add a row.
Does applicant own, operate or lease aircraft?
- Yes
- No
If yes, describe aircraft, and frequency of use for employee transportation:
Is any work performed below ground or above 15 feet?
- Yes
- No
If yes, please describe:
Is there an evacuation plan in place?
- Yes
- No
If yes, please describe:
Is there access to medical facilities?
- Yes
- No
If yes, please describe:
Please describe housing accommodations (who provides it, type of housing, location, security provided, on site or off, etc.):
Please describe transportation method for getting exmployees to the job site and security measures provided during transportation:
Please describe security measures provided at job site:
Please describe employee hiring criteria:
Applicant Signature:*
Date:*
Date Format: MM slash DD slash YYYY
Producer Signature:*
Date:*
Date Format: MM slash DD slash YYYY
By signing this application you're attesting to the fact that the information provided on this application is true and correct to the best of your knowledge, and that no material or relevant information has been suppressed or misstated. If a policy is issued it is based on the representations provided on this application and if an event occurs or information changes prior to the effective date of application written notice must be provided to the insurer. Changes in information and circumstances do allow the insurer to withdraw an offer of coverage and/or binding. Intentional omissions, misrepresentations or concealment of facts on this application allow for rescission of policy, quote or binding. Signing this application does not bind coverage, nor does acceptance of this application bind coverage.*
- I Agree

May 8th, 2015 by Worldwide Risk Management, Inc.

Job Classification	US Payroll	US #	3rd Country Payroll	3rd Country #	Local Payroll	Local #

Site Location Country	Site Location City/Base	# of US	# of 3rd Country	# of Local

Defense Base Act Insurance Application

Applicant Information

Producer Information

Coverage Information