El Dorado Insurance Agency, Inc.: Security Officer Program Renewal Questionnaire

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SECURITY OFFICER, ARMORED CAR, PATROL, DETECTIVE OR INVESTIGATIVE
GENERAL LIABILITY RENEWAL APPLICATION

Please complete the entire form below to receive a quotation for El Dorado's custom tailored Security
Industry General Liability Renewal 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. Named Insured:

2. Street Address: City, State, Zip

3. GL Expiring Policy #: (required) License #: RECEIPTS

4. Policy Effective Dates: GL: WC: Auto:

5. Application Classification:	% Security Service	% Investigation
5. Application Classification:	% Consulting	% Alarm Service

6. Total number of officer hours billed annually EXCLUDING Owner(s): UNARMED ARMED

7. Total number of officers:	FT UNARMED	PT UNARMED
7. Total number of officers:	FT ARMED	PT ARMED

8. Have there been any changes in the operations? (Dogs, Janitorial, Etc.):

9. Do any of your officers use tasers in their operations? YesNo

10. Number of Owner(s) Performing Security Officer Work?

11. Provide the names of your five largest revenue-producing clients and a description of your duties:

12. List Annual Payroll Separately by Category (Excluding Owner(s)):

	Armed Payroll	Unarmed Payroll
Airports
Retail (outside, parking lots, etc)
Retail (inside, shoplifting, door duty)
Industrial (warehouse, factories, etc)
Schools
Churches
Hospitals
Special Events (concerts, sporting events, etc)
Liquor Serving Establishments (bars, clubs, taverns, liquor stores)
Fast Food Restaurants
Restaurants
Patrol Cars (alarm response, patrol service)
Construction Sites
Housing/Residential - Low Income
Housing/Residential - Mid & Upper Income
Traffic Control
Hotels/Motels
Banks
Office Buildings
Government Contracts
Money or Valuables Handling/Transportation Courier
Executive Protection/Bodyguard Service
Private Investigations, Insurance, Legal, Credit, Pre-Employments
Lie Detection, Polygraph, PSE
Process Service
TOTAL ANNUAL PAYROLL FOR OFFICER SERVICES
TOTAL ANNUAL PAYROLL FOR SUPERVISORS
GRAND TOTAL OF PAYROLL

Notice to applicants: The quote will be based on the information provided. Any person knowingly filing an application
for insurance containing false information or concealing information containing any material fact thereto, has committed
a fradulent insurance act, which is a crime. By submitting this application, the insured warrants that to the best of
their knowledge all information is accurate.

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