El Dorado Insurance Agency, Inc.: Alarm General Liability Application

Description of Loss

Amount Incurred

Open/Closed

Private Security • Alarm Installers • Private Investigators • Process Servers • Fire Safety • Armored Car • Polygraphers • Locksmiths • Reposession & Recovery Agents

Security Services • The El Dorado Advantage • Request More Information • ONGUARD • Online Resources • EMail • El Dorado Home

ALARM GENERAL LIABILITY APPLICATION

Please complete the entire form below to receive a quotation for El Dorado's custom tailored Alarm
General Liability Coverage. Use the "tab" key or your mouse (not the "return" key) to easily navigate
between the fields. Your information will be sent to a secure server and will be held in complete confidence.

One of our specialists will contact you as quickly as possible with your final estimate.

1. Applicant:

2. Street Address: City, State, Zip

Mailing Address (if different than above):

Additional Locations (if any):

d. If additional space is necessary, please email or fax additional worksheet.

3. Name of contact person for inspection/audit: Telephone No.:

4. Email Address: (required)

5. Applicant is: Individual Corporation Partnership Other (Describe):

6. Coverages: Effective Date: (required)

7. Limits: $ Each Occurrence $Aggregate

8. Deductible: $Including Loss Adjustment Expense

9. Applicant Operations: % Alarm % Safety Equipment % Other:

10. How long has Applicant owned this business?

11. How many years experience does Applicant have in this field?

12. Is Applicant involved in any other operations? Yes No
If yes, please describe:

13. Describe the duties of owner:

14. Provide the names of Applicant's five largest clients and a description of your duties for them:

15. Signed contract with all customers? Yes No

16. Percent % of customers under standard contract: %

PLEASE EMAIL OR FAX COPY OF YOUR STANDARD CUSTOMER CONTRACT OR PURCHASE ORDER.

17. Pre-employment Screening Procedure (check applicable):

Prior Employment Check	Drug Screening	Personal Reference	Psychological Testing
Polygraph	MVR	Background Check	Other
Please describe "Other":

18. Training Program Consists of (check applicable):

Written Manual	Report Writing	CPR	On The Job
Firearms	Use Of Force	Powers Of Arrest	Other
Please describe "Other":

19. Is the Applicant licensed? Yes No
If yes, please list licenses:

20. Does Applicant perform any work at facilities where explosives are handled or stored or at nuclear power plants? Yes No
If yes, please describe:

21. Does Applicant perform any design work? Yes No
If yes, please describe:

22. Describe Trade Association Memberships held:

23. Claim/Loss History over last five (5) years: If none, so state. (Email or fax Carrier Loss Runs)
Verified loss runs required to bind.

Describe any additional incidents that have occurred that may result in a claim being made against Applicant. If none, so state:

24. Policy Information:

Carrier	Policy Period	Limits of Liability	Deductible	Premium

25. Has any carrier cancelled or refused to renew? Yes No
If Yes, please describe:

26. ALARM COMPANY OPERATIONS - Please provide $ breakdown of applicable operations:

Payroll	Receipts
		Sales/Distribution
		Service
		Installation
		Manufacturing
		Other
Please describe "Other":

27. Alarms are:

% Fire	% Combination	% Water Flow
% Burglary	% Medical Alert	% Temperature Control
% Other (intercom, etc.)

28. If Applicant does not monitor alarms, who does?

29. Written contract with monitoring company? Yes No
If applicable, please email or fax copy of contract with monitoring company

30. Please fully describe alarm response procedures:

31. Customers are: % Commercial % Residential % New Construction

32. Customers: Number Under Contract $ Annual Contract Cost

33. Are independent contractors used? Yes No $ Annual Contract Cost

34. Does Applicant install or service safety equipment in nursing homes, medical, correctional, or detention facilities? Yes No

35. Is Applicant covered under Broad Form Vendors coverage by manufacturer? Yes No

36. Does the Applicant install safety equipment in buildings over four (4) stories? Yes No

37. Please add any questions or comments:

Check this box before sending (required)

800.221.3386 • 713.521.9251
Fax 800.700.0126 • 713.521.0125
2515 North Blvd. • Houston, Texas 77098