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DBA (Defense Base Act) Workers Compensation & Liability
Quote Request
Please complete the Information Request Form and we will contact you as soon as possible.
Organization:
Principle Mailing Address:
Principle Contact Name:
Phone - Fax - Email:
U.S. Contact Address (if applicable):
U.S. Contact Name (if applicable):
Phone - Fax - Email:
Nature of Business / Description of Operations:
Website:
Type of Organization:
Individual
Partnership
"S" Corp
Not for Profit
LLC
Corporation
Joint Venture
Years in Business:
To be completed for each contract RFP or multi-base contract. Please include a statement of work.
Contract # or RFP #:
Type of Contract:
USAID
DOD
State Department
Other
Length of Contract (please provide dates):
Description of the contract and operations. Please attach or forward a copy of the contract if available:
File Upload:
Country:
Name of Military Base:
US Expats: Number of Employees - Payroll by Occupation - Job Function or WC Class Codes - State or Country of Hire:
3rd Country Nationals: Number of Employees - Payroll by Occupation - Job Function or WC Class Codes - State or Country of Hire:
Local Nationals: Number of Employees - Payroll by Occupation - Job Function or WC Class Codes - State or Country of Hire:
Has the insured obtained a waiver of DBA benefits for Local National employees from the US Dept. of Labor?
Please select...
Yes
No
What type of housing is being provided for the employees?
Is housing located on the military base?
Please select...
Yes
No
What type of transportation is being provided to get teh employees to and from the workplace?
What type of security is provided for the employees both on and off base and during transportation?
Describe any other security measures or precautions that will be implemented:
Upload all relevant documents:
File Upload:
Comments:
Do not enter anything in this field:
If you have questions, or would like more information, please leave your name and contact information.
Business Name
*
Contact Name
Contact Email
*
Contact Phone
DBA Location(s) Outside the U.S. (City Country)
*
Number of employees Working Abroad
*
Additional Comments or Requests
Do not enter anything in this field:
*
indicates a required field
Please fill this field.
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