Section I - General Information

Insured's Name (including dba’s) 

Mailing Address: 

City: 

State: 

Zip: 

Physical Address: 

City: 

State: 

Zip: 

Contact:

Title:

Phone:

Cell:

Fax:

Effective Date Desired:

(Check one) Individual: 

Partnership: 

Corp: 

Other: 

FEIN:

License Number(s):

Email Address:

How long in the Security business?

How long under this name?

Has the applicant operated under any other name?

If yes, please identify:

Application Classification:

Limit of Liability desired

Each Occurrence: 

Aggregate: 

In regards to your clients, do you assume any duties not related to security?
(if yes, please explain)

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

Are the majority of your clients under contract?

If yes, how many include hold harmless clauses?

Is workers’ compensation coverage currently in force?
(if no, please explain)

Section II – Operations

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

Will the principals perform guard/investigative operations?

Number of supervisors: 

Please describe duties of supervisors:

Average numbver of officers per supervisor? 

Employee training consists of: 

Pre-Employment screening procedures for employees
(check all that apply):

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

Number of officers:

Do you use any golf carts for patrol?
(if yes, how many)

If yes, are they equipped with lights?

Will the public be transported?

Are driving records checked?

Do you anticipate using dogs?
*Must be leashed not to extend 6ft.

Number of dogs used with handlers:

Without handlers:

Do any of your officers use tasers in their operations?

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

Of what professional associations are you a member?

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

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

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:

Annual Corporate Revenue:

Alarm Operations:

Please provide a description of all alarm operations:

Section IV – 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:

Section V – Current Insurance Information

Current Carrier?

Inception date:

Expiration Date:

Premium:

Deductible:

Limit of Liability:

Occurrence Form?

Has any company cancelled or declined to renew liability insurance?

If yes, please explain:

Do you require staff to report all unusual incidents to management?

Have there been any claims or lawsuits in the past 5 years?

If yes, please explain:

***PLEASE ATTACH FIVE YEARS OF COMPANY LOSS RUNS***

Do you have any knowledge of any incidents which may give rise to a future claim?

If yes, please explain:

Applicant Name 

Applicant Title 

Date