Section I - General Information

Insured's Name (including dba’s)

Mailing Address:

City:

State:

Zip:

Physical Address:

City:

State:

Zip:

Branch Locations:

Please list any additional states in which you conduct business:

Contact:

Title:

Phone:

Cell:

Fax:

Current Expiration Date:

Expiring Policy Number:

Application Classification:

% Security Service
% Investigations
% Consulting
% Alarm Service and Monitoring

(Check one) Individual:

Partnership:

Corp:

Other:

FEIN:

License Number(s):

Total number of hours billed to client(s) annually:

Unarmed:
Armed:

Number of officers:

Full Time Part Time
Unarmed Armed

Email Address:

How long in the Security business?

How long under this name?

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

Yes
No

If yes, please explain:

Do any of your officers use tasers in their operations?

Yes
No

Any operations performing security services where jewelry, money, securities or furs are present?

Names of Owner(s), Partner(s) and Shareholder(s), their percentage of ownership and background in this industry:

Number of owners performing security officer work?

Please provide a list of your (5) five largest clients, along with a description of services:

Section II – Projected Annual Payroll
(Not Including Owners and Clerical Staff)

****Your liability insurance carrier defines Independent Contractors as workers who carry their own license and their own liability insurance. All other employees who are 1099 or W2 are considered “on the payroll” and their salaries should be included on the table below.

Based on the above definition, do you have any independent contractors?

Yes
No

If yes, please give their total salaries:

Guard Services	Unarmed Payroll	Armed Payroll
Airports (non-public)**
Airports (public)**
Armored Car
Banks
Bounty Hunting / Bail Enforcement
Car Dealerships
Churches
Construction or Demolition Sites
Convention/Trade Shows
Criminal Detention Centers**
Executive Protection
Fast Food Establishments
Federal Government Contracts
Gated Communities/Retirement
Government-Owned Housing**
Hotels/Motels
Industrial (Factories, Warehouses, Etc.)
Institutions (Hospitals, Clinics)
Liquor Establishments (Bars, Taverns, Etc)
Local & State Contracts
Middle/High Income Housing**
Museums/Galleries
Office Buildings
Patrol Cars
Restaurants
Retail Stores (Parking Lots, Outside Perimeter)**
Retail Stores (Inside, Shoplifting, Door Duty)**
Schools
Special Events (Sports, Concerts, Etc)**
Strike Duty
Traffic Control
Transport/Courier Operations
Trucking Terminals
Waterfront/Piers/Marinas
Other**
Private Investigations	Unarmed Payroll	Armed Payroll
Executive Protection / Bodyguard Service**
Insurance, Legal, Credit, Pre-Employment
Lie Detection, Polygraph
Process Server
Security Consultant**
Total

**Please refer to Section IV for a further explanation of operations

Average Hourly Wage:

$ Full Time
$ Part Time

Annual Corporate Revenue:

$ Full Time

Alarm Operations:

$ Estimated Revenue

Please provide a description of all alarm operations:

Section III – Description of Operations

Please provide complete details of the following operations, if applicable.

Airport Work – Please describe all operations / duties performed:

Apartment Work – Please describe duties. If any government-owned, please provide list of addresses:

Criminal Detention Centers – Please describe all operations / duties performed:

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

Special Events – Please describe events, locations, and duties:

Bodyguard Work – Please describe duties. Any celebrities, entertainers, or athletes?

Security Consulting – Please describe consulting clients and scope of services provided:

Other – Please describe all operations / duties performed:

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 signing 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.

Applicant Name

Applicant Title

Date

El Dorado Insurance Agency, Inc
In California dba El Dorado Security Services Insurance Agency – License #0E59720

Security Industry General Liability Renewal

Section I - General Information

Section III – Description of Operations