Foreign Legal Liability Application

Complete the form.
Click Submit and the completed form will be emailed to Bonnie Ridolfino at Hardenbergh Insurance Group
If you have any questions, please feel free to contact Bonnie at bonnie@hig.net

General Information
District Name:*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Contact Name*
First Last
Email*
Phone*
Quote Needed By*
Date Format: MM slash DD slash YYYY
Description of Foreign Trips planned within a 12-month period (# of days and all countries visited)*
Number of Employees*
Number of Students*
Number of Volunteers*
Separate Applications Required for*
- Kidnap & Extortion
- Property
- Defense Base Act
- None of the Above
Trip Travel Exposure for Students/Chaperones
What activities are performed by your students/chaperones while outside the United States?*
- Conferences, conventions, seminars, on-site inspections, field engineering studies, cultural/sightseeing trips
- Physical/manual Labor
Applicant Full Name (This acts as your signature)*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY

General Information