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Defense Base Act Rate Request

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Description of Operations
Insurance Term

	Payroll Exposure U.S. Nationals	Number of U.S. Nationals	Payroll Exposure Third Country Nationals	Number of Third Country Nationals	Payroll Exposure Local Nationals	Number of Local Nationals	Total Payroll Exposure	Total Number of Employees
Total Exposure
Maximum Employee Concentration (non-Iraq)**
Iraq (North of 36th parallel)
Iraq (South of 33rd parallel)
Iraq (between 33rd & 36th)
Conveyance Concentration (maximum employee concentration at any time)
Land (Auto/bus)
Air
Water
Maximum Employee Concentration means the greatest number of employees at a given location at a given time (e.g., all employees reside at the same hotel or sleeping quarters; or number of employees by job shift at a given site or building) Iraq Please clarify the 'Maximum Employee Concentration' by geographic location reflected above.

Does applicant check insurance on all (sub)contractors working at the DBA site? (Note: Any subcontractor you use must also procure DBA, else the sub falls under your program and a charge will be assessed)
Written Waiver from the Department of Labor for non-U.S. employees (TCNs &/or LNs)?	(if 'yes', please provide copy)

Describe Security Measures at each site above
(e.g., fenced compound? alarm system? CCTV? armed or unarmed guards?):

Describe Medical Facilities at each site above
(e.g., number of doctors, nurses, operating rooms):

Describe any evacuation plans in place:

Please provide most recent loss information, if applicable:

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