EUROPEAN-AMERICAN INC.

ACCIDENT Insurance Questionnaire
Please complete and return to EurAm
Company Name Street
Type of Applicant City
Telephone County
Telefax State / Zip
Website e-mail
    Federal Employer ID Number
Nature of Business:
Description of Aircraft owned or leased by your Firm
Make Model
Cert. No. No. of Passenger Seats:
No. of Crew Seats    
Do you wish to provide coverage on all employees while flying in above aircraft? yes no
including crew? yes no    
BUSINESS ONLY
Employee Classification
Class 1
Class 2
Class 3
Executive
Administrative
Sales
Benefits Amounts Desired
1.Fixed Dollar Amount per Employee
$
$
$
2.Multiple of salary per employee - if yes, please click here for separate sheet
Travel resume (Based upon travel outside the city of permanent assignment during past 12 months.) -      


a.) Total number of employees who travel on company business.
b.) Number of employees who travel 50 or more days per year.
c.) Average number of days of travel per person per year (excluding those travelling 50 or more days).


BUSINESS AND PLEASURE
Employee Classification
Class 1
Class 2
Class 3
Executive
Administrative
Sales
Benefits Amounts Desired      
1.Fixed Dollar Amount per Employee $ $ $
2.Multiple of salary per employee - if yes, please click here for separate sheet      

 

Number or Employees

 


Note: Completion of this application does not constitute a binder or obligate the applicant to purchase this insurance.

Desired Effective Date    
Name: Title: Date: