El Dorado Insurance Agency, Inc.: Private Investigator General Liability Renewal

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PRIVATE INVESTIGATOR & SECURITY CONSULTANT RENEWAL

Please complete the entire form below to receive a quotation for El Dorado's custom tailored Private
Investigators 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

3. License #:

4. Email Address: (required)

5.   Please advise if address/phone #'s have changed
       Physical Address:
       Phone #:   Fax #:   Alternative #:

6. Your Commercial General Liability Insurance expires on:

7. Have you incurred any losses over the past 3 years? Yes No If yes, please email or fax summary of losses.

8. Estimated Annual Investigative/Process Server Payroll for EMPLOYEES ONLY
(this amount should NOT include owner/partner/executive officer payroll):

9. Estimated Subcontractor/Independent Contractor cost*:
*Include only if contractors do not carry their own liability insurance

10. Estimated Annual Sales/Receipts:

11. Number of owners, partners, & executive officers who work as investigators/process servers/consultants:

12. Total number of employees: Investigators: Consultants:

13. Indicate percentage of work done in each category:

%	Credit/Pre-employment	%	Executive Protection
%	Insurance/Legal	%	Auto Reposessions
%	Missing Persons	%	Process Serving
%	Domestic	%	Undercover
%	Bail Enforcement	%	Shopping Service
%	Fire/Arson	%	Special Events
%	Accident	%	Computer
%	Other (Describe Below)	%	Polygraph

	Other - Please describe all operations/duties performed:

14. Security Consultation:

%	Physical Security	%	Kidnap/Terrorist
%	Construction Design	%	Seminars/Lectures
%	Data/Computer Security	%	Criminal
%	Other (Describe Below)

	Other - Please describe all operations/duties performed:

15. Does your firm provide any type of security guard operations (ie: executive protection, bodyguard, etc)? Yes No

If yes, indicate percent of operations: % and provide details:

16. 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