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

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PRIVATE INVESTIGATOR & SECURITY CONSULTANT APPLICATION

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. Company Name:

2. Street Address: City, State, Zip

3. Proposed Effective Date: (required)

4. Select limit of liability desired: $100,000 $300,000 $500,000 $1,000,000

5. Phone No.: Fax No.:

6. Email Address: (required)

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

8. Date established:

9. Federal ID Number: License Number:

10. Person to contact: Title:

11. Are you an ASIS member? Yes No

12. What background do the principals of this organization have in the Investigative/ Security Consultation Industry?

13. Total number of employees: Investigators: Consultants:

14. Annual receipts: Payroll: Sub-contractor expense:

15. Are sub-contractors' Certificates of Insurance on file? Yes No

16. Indicate % of operations:

Private Investigation
%	Credit/Pre-employment	%	Asset Searches
%	Insurance/Legal	%	Background
%	Criminal	%	Missing Persons
%	Domestic	%	Accounting Fraud
%	Reposessions	%	Process Serving
%	Fire/Arson	%	Child Custody
%	Accident	%	Record Services
%	Special Events (Describe Below)	%	Computer Crime
%	Shopping Services	%	Skip Tracing
%	Environmental	%	Surveillance / Electronic
%	Executive Protection	%	Expert Witness
%	Other (Describe Below)	%	White Collar Crimes
Security Consulting
%	Physical Security	%	Construction Design
%	Data/Computer Security	%	Kidnap/Terrorist
%	Criminal	%	Seminars / Lectures
%	Threat Assessment	%	Firearms Training - Classroom
%	Firearms Training - Range	%	Training (Other)
%	Other (Describe Below)
Lie Detection
%	Paper / Pen & Pencil	%	Psychological Stress Evaluator
%	Polygraph	%	Other (Describe Below)

	Special Events - Please describe all operations/duties performed:

	Other - Please describe all operations/duties performed:

17. 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:

18. Current Carrier: Current Premium:

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

20. Training: (please provide the number of hours of training for each category)
Total number of annual training hours: On-the-job training:
Classroom training: Other, describe:

21. Pre-Employment Screening:
Fingerprints: Yes No Drug Testing: Yes No Honesty Testing: Yes No
Psychological Testing: Yes No Prior Employer: Yes No Personal Interview: Yes No

22. 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