El Dorado Insurance Agency, Inc.: Security Officer General Liability Questionnaire

Description of Loss

Amount Incurred

Open/Closed

Private Security • Alarm Installers • Private Investigators • Process Servers • Fire Safety • Armored Car • Polygraphers • Locksmiths

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

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

Please complete the entire form below to receive a quotation for El Dorado's custom tailored Security
Officer 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. Company Name: *

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: *

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

6. Coverages: Effective Date: *

7. Limits: $ Each Occurrence $ Aggregate

8. Deductible: $ Including Loss Adjustment Expense

9. Applicant Operations: % Security Officer % Armored Car % Patrol % Detective/Investigative

10. Payroll by Operation: Please provide percentage breakdown of officer, armored car, patrol, detective and investigative
operations by the following categories that are applicable.

%	Hospitals	%	Shopping Malls - Interior Patrol
%	Schools	%	Shopping Malls - Parking Lot Patrol
%	Car Dealerships	%	Bail Bonds
%	Churches	%	Bounty Hunting
%	Government Facilities (Describe Below)	%	Concerts (Describe Below)
%	Banks	%	Athletic Events (Describe Below)
%	Office	%	Armored Car/Courier/Money Escort
%	Airports (Describe Below)	%	Traffic Control
%	Body Guard (Describe Below)	%	Shoplifting Surveillance (Describe Below)
%	Hotels/Motels	%	Employee Surveillance
%	Construction Sites	%	Process Serving
%	Residential Patrol	%	Polygraph Administration/Validation
%	Apartments (Describe Below)	%	Consulting (Describe Below)
%	Condominiums	%	Training Schools (Describe Below)
%	Low Income Housing Projects	%	Repossession/Collection Work
%	Warehouses	%	Record Checks
%	Manufacturing Plants	%	Credit/Pre-Employment Checks
%	Strike Work	%	Child/Missing Person Searches
%	Fast Food Restaurants	%	Insurance Investigation
%	Restaurants Other Than Fast Food	%	Arson Investigation
%	Liquor Stores	%	Alarm Response
%	Bars/Lounges	%	Other - Please Describe:
%	Retail Stores (Describe Below)

	Government Facilites - Please describe all facilities where work is performed (i.e., offices, train station):

	Airport Work - Please describe all operations/duties performed:

	Body Guard Work - Please describe duties performed. Celebrities, Entertainers, or Athletes? If so, who?

	Apartment Work - Please fully describe duties. Any subsidized/low income housing locations? Yes No

	Retail Work - Please describe types of stores, duties performed, and hours that guard(s) are on duty:

	Shoplifting Surveillance - Please fully detail arrest/detention responsibilities:

	Concerts - Please fully describe performers and locations, as well as duties (i.e. - crowd control, traffic control):

	Athletic Events - Please describe event, location and duties (i.e. - crowd control, traffic control):

	Consulting - Please describe who you are consulting for and the scope of consulting services you are providing:

	Training Schools - Please describe who you are training and the scope/purpose of the training being provided:

11. Rating Information:

a. Annual Officer, Armored Car, Patrol and Investigative Payroll: $ * Receipts: $

# of Full-Time Officers: Full-Time Payroll: $

# of Part-Time Officers: Part-Time Payroll: $

Independent Contractors - Cost: $

b. Annual Number of Billed Hours: *

c. Average Hourly Wage: Full-Time: $ per hour Part-Time: $ per hour

d. Number of Armed Officers: Number of Unarmed Officers:

Where are officers stationed:

e. Number of Canines: Attended Unattended

How and where are canines used? Please describe any drug or bomb sniffing activities:

f. Number of Supervisors: Total Payroll: $

Describe duties:

f. Training - Please describe how officers are trained (i.e.: on-the-job, formal training program):

12. General Information:

a. How long has Applicant owned this business: *

b. How many years experience does Applicant have in this field: *

c. Owner(s) duties:

d. Is Applicant involved in any other operations: Yes No

If yes, please describe:

e. Has any carrier cancelled or refused to renew Applicant's business: Yes No

If yes, for what reason:

13. Claim/Loss History over last five (5) years: If none, so state. (Email or fax Carrier Loss Runs)

14. Policy Information:

Carrier	Policy Period	Limits of Liability	Deductible	Premium

15. Trade Association Membership held:

16. Please add any questions or comments:

NOTICE TO APPLICANTS: This application must be completed in full as the quote will be based solely on the information provided.
Any persons who knowingly and with the intent to defraud any insurance company or other person, files an application for insurance
containing any false information, or conceals for the purpose of misleading information concerning any fact material thereto,
commits a fraudulent act, which is a crime. Be aware of the laws in the states where you operate with regard to the use of firearms
and weapons. By clicking below, you are verifying that you 1) are aware of, understand, and comply with the laws of the states in
which you operate and 2) are aware that any claim you submit where an illegal device was used by you, your employee, or a
subcontractor doing work for you may be denied.

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