Political Violence Application


a. Applicant and all subsidiary companies to be insured under this policy
b. Applicant's mailing address

2. Limits of liability requested for buildings, contents, and business interruption

a. Total each Loss
i. Buildings each Loss
ii. Contents each Loss
iii. Business Interruption each Loss
b. Total each Policy Year

3. Deductible requested

4. Policy currency to be used


a. Description of applicant's business operations at the locations to be insured
b. Status of applicant
c. How important to operation are computer and data processing?

6. Building, contents, and business interruption values at the location to be insured

Business Interruption

7. Physical description of location(s) to insured

8. Description of area surrounding location(s) to be insured

a. Describe occupants of surrounding buildings
b. Is it an area known to suffer from an above average crime rate?
c. Distance from nearest police station or army post

9. Description of employees and operations at location(s) to be insured

a. Number of employees and operating hours at each location
b. Details of ethnic minorities, labour relations, and unions at each location
c. Number and location of employees in building(s) outside normal working hours
d. Are cleaning staff in-house or contract and what are their hours?
e. What businesses occupy other parts of the building(s) to be insured?
f. Do these other businesses attract press or public attention?

10. Description of security at location(s) to be insured

a. Details of guard force, number, reports to whom, recruitment, training, duties. Details of alarm systems, CCTV etc
b. Details of key system and control
c. Details of perimeter fence and gates
d. Details of access control procedures and equipment
e. How is the building lit (inside and outside)?
f. Who locks the building at night?
g. Details of car parking arrangements

11. Description of past history at location(s) to be insured

a. Give full particulars of any incidents or threats in the past 5 years
b. Describe steps taken to deal with them and to prevent recurrence
c. List all property loss for last 5 years

12. Does the applicant, its directors and officers or any other known person have knowledge or information of any specific fact which may reasonably give rise to a claim under the proposed policy?

13. Covered causes of loss(not covered unless specified here)

Insured peril
Cover purchased by insured
Act of terrorism
Riots, Strikes and/or Civil Commotion
Malicious Damage
Insurrection, revolution or Rebellion
Mutiny and/or Coup d'Etat
War and/or Civil War
The Undersigned authorized officer of the corporation declares to the best of his knowledge that the statements
Authorized Signature of Applicant
Name and title of authorized officer