Section I - General Information

Applicant Legal Name (including dba’s) 

Name To Appear On Company License: 

Owner: 

Contact Person/Title: 

Phone: 

Fax: 

Email Address: 

Mailing Address: 

City: 

State: 

Zip: 

Location Address: 

City: 

State: 

Zip: 

Company License #(s) 

(Check one) Individual: 

Partnership: 

Corp: 

Other: 

Number of Years in Business: 

FEIN#: 

Effective Date Desired: 

Limits of Liability 

Occurrence: 

Products/Completed Operations: 

Aggregate: 

****VERY IMPORTANT!!****
The Carrier will not allow a quote to be released until they have reviewed your company’s contract.Please return with application. The “limitation of liability” or “liquidated damages” must be legible.

Section II – Total Estimated Annual Revenue

Estimated Revenue for
next 12 months: 
(not including monitoring revenue) 

Estimated Monitoring Revenue: 

Percentage of revenue 
generated by jobs subcontracted 
to insured companies: 

Number of Technicians: 
not including owner(s) 

Annual Payroll Technicians 
not including clerical/ 
administrative/owner(s): 

Revenue previous 12 months: 

Owner Payroll: 
(only if Field Work is 
performed by owner(s)) 

Section III – Current Insurance Information

Carrier: 

Expiration Date: 

General Aggregate: 

Occurrence: 

Claim History: 
(please provide 5 years current loss runs) 

Premium: 

Section IV – Operations

Do you operate in any other states?: 

If yes, please list: 

Operations are:

Client Base:

** Please describe the type of work being done for New Home Builders i.e. tract homes, condominiums, custom homes. A “tract home” is defined as a development of five or more individual and freestanding houses which share common or similar design elements, floor plans, blueprints and/or architectural details, and/or which are constructed at the same time, or consecutively, on the same parcel, adjacent parcels, or parcels so located within one geographic area to be considered a single project.

Description: 

If a portion of the work you are doing for new home builders is for tract homes or condos and another portion is for custom homes, please provide percentages for each (must equal 100%)

Tract homes, condos, townhouses: 

Custom Homes: 

Total number of customers: 

Number under contract: 

Do you install alarm or service safety equipment in:

Nursing homes (yes/no): 

Medical facilities (yes/no): 

Correctional facilities (yes/no): 

Detection facilities (yes/no): 

If yes, what percentage of your 
total work is designated to this? 

Does your company do its own monitoring? 

If not, please provide name of 
monitoring companyDetection facilities: 

Section V – Alarm Response

Do you provide security/patrol 
response to your customers 
if and when Police/Fire/EMT’s 
do not respond?: 

If yes, are the responders employees or hired/contracted for this service? 

Fully describe alarm response procedures: 

If responders are not employees, 
do you have a written contract 
with the security company that 
provides the response? 

If you have a contract with the security company, is either part holding the other harmless/providing indemnification? 

If yes, provide details: 

Do any employees or 
subcontractors carry firearms? 

Completed by: 

Title: 

Date: 

****VERY IMPORTANT!! ****
The Carrier will not allow a quote to be released until they have reviewed your company’s contract. Please return with this application. The “limitation of liability” or “liquidated damages” section must be legible.