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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Coverage Information
Proposed Effective Date:
Proposed Expiration Date:
Entity Type:
Corporation
LLC
Joint Venture
Individual
Partnership
Other
Years in Business:
Prior DBA Coverage?
Yes
No
Type of Contract:
DOD
DOS
USaid
US Army Corp of Engineers
Other
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:
*
Producer Signature:
*
Date:
*
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
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May 8th, 2015
by
Worldwide Risk Management, Inc.