Active Assailant Insurance Application

Please complete the following application to request a quote for Active Assailant Insurance coverage. The information provided will be used by underwriting to evaluate eligibility and determine coverage options. This application typically takes less than 15 minutes. If you have any questions, please email submissions@thinkcga.com.

"*" indicates required fields

Step 1 of 6

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This field is for validation purposes and should be left unchanged.

General Information

Today's Date*

Brokerage Name*

Brokerage Contact (Name)*

Brokerage Email (Contact's Email)*

Brokerage Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Named Insured Details

Application of Insurance For (Named Insured)*

Effective Date Requested*

Expiration Date*

Company Website

Contact Name*

Contact Email*

Contact Phone Number*

Primary Physical Street Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is the Mailing Address Different than the Primary Physical Street Address*

Yes

Primary Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Authorization & Consent

Fraud Statement

The Undersigned Insurance Broker And Applicant Declare That To The Best Of Their Knowledge And Belief And Warrant That The Statements Set Forth Herein Are True. The Undersigned Further Declares That Any Occurrence Or Event Taking Place Prior To The Effective Date Of The Insurance Applied For Which May Render Inaccurate, Untrue, Or Incomplete Any Statement Made Will Immediately Be Reported In Writing To The Insurer And The Insurer May Withdraw Or Modify Any Outstanding Quotations And/Or Authorization Or Agreement To Bind The Insurance. The Insurer Is Hereby Authorized, But Not Required, To Make Any Investigation And Inquiry In Connection With The Information, Statements And Disclosures Provided In This Application. The Decision Of The Insurer Not To Make Or To Limit Any Investigation Or Inquiry Shall Not Be Deemed A Waiver Of Any Rights By The Insurer And Shall Not Stop The Insurer From Relying On Any Statement In This Application In The Event The Policy Is Issued. Any Person Who Knowingly And With Intent To Defraud Any Insurance Company Or Other Person Files An Application For Insurance Containing False Information Concerning Any Material Fact Thereto, Or Conceals Information For The Purpose Of Misleading, Commits A Fraudulent Insurance Act, Which Is A Crime.

Applicant Name*

Applicant Title*

Date*

Applicant's Signature*

By signing below, you certify that the information provided in this application is true and complete.

Agent/Broker Name*

Active Assailant Insurance Application

General Information

Named Insured Details

Business Details

Underwriting Questions

Prior Incident/Claim History

Available Coverage Endorsements

Authorization & Consent

Fraud Statement