El Dorado Insurance | Applications

Section I - General Information

Insured's Name (including dba’s)
Mailing Address:
City:
State:
Zip:
Physical Address:
City:
State:
Zip:
Contact:
Title:
Phone:
Cell:
Fax:
Effective Date Desired:
(Check one) Individual:
Partnership:
Corp:
Other:
Limit of Liability desired
Occurrence:	$
Aggregate:	$
Email Address:
Date Company Established:
What background do the principals of this organization have in the Investigative/Security Consultation industry?
Federal ID Number:
License Number:
****Your liability insurance defines Independent Contractors as workers who carry their own license and their own liability insurance. All other employees who are 1099 or W2 are considered "on the payroll" and their salaries should be included on the next page.
Does applicant subcontract work to others?	Yes No

Do sub-contractors maintain their own insurance?	Yes No

Are Certificates of Insurance required from subcontractors?	Yes No

Do you require subcontractors to name you as an additional insured on their policies?	Yes No

Annual Sub-Contractor cost:	$

Does your firm provide any type of security, guard or alarm operations?	Yes No
If yes, explain:
Please provide a list of your types of clients, along with a description of services:
Section II – Operations

Total number of Owner(s):
Number of Owners performing Investigation(s):
Number of Employees Not Including Clerical, Sub-Contractors, Owner(s), partners, or Executive Officers:
Annual Corporate Revenue:
Employee training consists of:	Written Manual Report Writing Powers of Arrest On the Job Firearms CPR Other
Pre-Employment screening procedures for employees (check all that apply):	Polygraph Driving Record (MVR) Psychological Test Drug Screen Fingerprint Check Personal References Other
Please indicate % of operations (must be 100%)
Private Investigation
% Accident Investigations/Reconstruction % Asset Searches % Background Investigations % Bank & Accounting Fraud % Child Recovery / Custody % Computer Crime % Credit / Pre-Employment % Domestic (Matrimonial / Divorce) % Environmental % Executive Protection % Expert Witness** % Fire / Arson	% Insurance Investigations % Legal Investigations % Missing Persons / Heirs % Process Serving % Record Services % Repossessions % Shopping Services % Skip Tracing / Collections % Surveillance / Electronic % WC / Fraud Investigations % White Collar Crimes % Other
Security Consulting**
% Construction Design % Criminal % Data / Computer Security % Kidnap / Terrorist	% Seminars / Lectures % Terrorism % Threat Assessments % Other
Lie Detection
% Paper / Pen & Pencil % Polygraph	% Psychological Stress Evaluator % Other
Training
# Firearms Training – Classroom (students/yr) # Firearms Training – Firing Range (students/yr)	# Security – Classroom (students/yr) # Other** (students/yr)
**Please refer to Section III for a further explanation of operations
Section III – Description of Operations (If Applicable)

Accident Investigations/Reconstruction – Please describe all operations. Any fault assessment?	Yes No


Executive Protection – Please describe all duties performed: Any athletes, celebrities or entertainers?	Yes No


Expert Witness – Do you provide court testimony as an expert for cases that you are NOT investigating? If yes, please describe all operations/duties performed & provide resume:	Yes No


Fire / Arson – Please describe all operations/duties performed. Any cause of origin?	Yes No


Shopping Services – Please describe events, locations and duties:


Security Consulting – Please describe clients, scope of services performed & provide a sample contract:


Other – Please describe all operations / duties performed:


Applicant Name
Applicant Title
Date

El Dorado Insurance Agency, Inc In California dba El Dorado Security Services Insurance Agency – License #0E59720

Private Investigation General Liability (E & O) Renewal Application

Section I - General Information

Limit of Liability desired

Section II – Operations

Private Investigation

Security Consulting**

Lie Detection

Training

Section III – Description of Operations (If Applicable)