Security Industry Umbrella / Excess Application

Section I - General Information

Applicant's Legal Name
(First Named Insured)

Other Named Insureds (if any):

Applicant Trade Name (if any):

Mailing Address:

City:

State:

Zip:

Street Address:

City:

State:

Zip:

Additional Locations (if any):
(List all owned, leased, rented, occupied locations)

Date Business Started:

FEIN:

Website Address:

Name of contact person for inspection/audit:

Phone:

Name of contact person for accounting records:

Phone:

Applicant is:

Individual
Corporation
Partnership
Limited Liability Corporation
Joint Venture
Subchapter “S” Corporation
Not For Profit Organization

Is the Applicant a subsidiary of another entity?

Yes
No

If yes, please identify:

Does the Applicant have any subsidiaries?

Yes
No

If yes, please identify:

Any Policy or coverage declined, cancelled or non-renewed during the prior 3 years?

Yes
No

Section II – Prior Carrier Information

Category	Current Term	1st Prior	2nd Prior	3rd Prior	4th Prior
Carrier
Policy Number
Eff-Exp Date
Premium

Section III – Requested Coverages

$1,000,000	$2,000,000	$3,000,000	$4,000,000	$5,000,000
Annual Gross Payroll $ Annual Gross Receipts #

UNDERLYING INSURANCE: IF COVERAGE OVER AUTO LIABILITY OR EMPLOYERS LIABILITY IS DESIRED, PLEASE PROVIDE FULL COPIES OF LIABILITY APPLICATIONS PROVIDED TO PRIMARY UNDERWRITERS. (AUTO LIABILITY OR EMPLOYERS LIABILITY)

LIST PRIMARY POLICIES TO BE CONSIDERED AS UNDERLYING INSURANCE (If not applicable, please indicate N/A)
TYPE	CARRIER/POLICY#	EFF.DATE	EXP.DATE	LIMITS
AUTOMOBILE LIABILITY				CSL EA. ACC.	$
				BI EA. ACC	$
				BI EA. PER.	$
				PD EA. ACC.	$
GENERAL LIABILTY				EACH OCCURRENCE	$
				GENERAL AGGR	$
				PROD & COMP OPS AGGREGATE	$
				PERSONAL & ADV INJURY	$
				DAMAGE TO RENTED PREMISES	$
EMPLOYERS LIABILTY				EACH ACCIDENT	$
				DISEASE EACH EMPLOYEE	$
				DISEASE POLICY LIMIT	$

EXPOSURES – AUTO LIABILITY (If applicable)

Are explosives, caustics, flammables or other dangerous cargo hauled?

Yes
No

Any units not insured by underlying policies?

Yes
No

Are any vehicles leased or rented to others?

Yes
No

What is the Coverage Symbol for the Liability coverage under the Business/Commercial Auto policy?

How many employees does Applicant/Named Insured have in total?

Do any employees use their personal vehicles for business purposes/company business?

Yes
No

If Yes, how many?

Do any employees use their personal vehicles for business purposes/company business?

Yes
No

If Yes, how many?

Do any employees drive their personal vehicles to and from any work sites?

Yes
No

If Yes, how many?

Does Applicant/Named Insured collect and maintain Certificates of Personal Auto Insurance from employees, including Certificates for their policy renewals?

Yes
No

Does Applicant/Named Insured mandate a minimum limit of Auto Liability for employees who may use their personal autos for business?

Yes
No

Does Applicant/Named Insured verify that the employee’s personal autos are in good working order and regularly maintained (i.e., brakes, tires, lights)?

Yes
No

If Yes, provide details:

Does Applicant/Named Insured obtain and review driver MVRs before/during the hiring process?

Yes
No

Does Applicant/Named Insured regularly check driver MVRs during their employment?

Yes
No

If MVR record is poor, what corrective action is taken?

EXPOSURES – VEHICLES (If applicable)
TYPE		# OWNED	# NON-OWNED	# LEASED	PROPERTY HAULED	0-50 MI	50-200 MI	OVER 200 MI
PRIVATE PASSENGER
TRUCKS	LIGHT
	MEDIUM
	HEAVY
	EX HEAVY
TRUCKS/ TRACTORS	HEAVY
TRUCKS/ TRACTORS	EX HEAVY
BUSES

EXPOSURES – EMPLOYERS LIABILITY (If applicable)

Is Applicant self-insured in any state?

Yes
No

If Yes, please list states:

Please list states where operations are conducted; where any premises are maintained; or where employees are otherwise subject to Worker’s Compensation Regulations:

Subject to:

Jones Act
FELA

EXPOSURES – WATERCRAFT OR AIRCRAFT

Does Applicant own, charter, lease, borrow or otherwise operate any watercraft or aircraft?

Yes
No

If Yes, please provide details:

Section IV – Loss History

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

Yes
No

If yes, please explain:

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

State Notices: The following notices are required by the Insurance Department of the indicated states.
NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH 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 INSURANCE ACT WHICH IS A
CRIME. (Note: This notice is required by New York insurance regulations, but may also be a crime in other states.)
NOTICE TO TENNESSEE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER, FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
THE UNDERSIGNED DECLARES THAT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE SIGNING OF THIS APPLICATION DOES NOT BIND THE UNDERSIGNED TO PURCHASE INSURANCE, NOR DOES REVIEW OF THE APPLICATION BIND THE INSUROR TO ISSUE A POLICY. IT IS AGREED, HOWEVER, THAT THIS APPLICATION SHALL BE THE BASIS OF THE
CONTRACT SHOULD A POLICY BE ISSUED.

Applicant Name

Applicant Title

Date

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

NOTICE:

1. THE INSURANCE POLICY THAT YOU ARE APPLYING TO PURCHASE IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED “NONADMITTED” OR “SURPLUS LINE” INSURERS.

2. THE INSURER IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT WHICH APPLIES TO CALIFORNIA LICENSED INSURERS.

3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED.

4. CALIFORNIA MAINTAINS A LIST OF ELIGIBLE SURPLUS LINE INSURERS APPROVED BY THE INSURANCE COMMISSIONER. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE: WWW.INSURANCE.CA.GOV.

5. FOR ADDITIONAL INFORMATION ABOUT THE INSURER YOU SHOULD ASK QUESTIONS OF YOUR INSURANCE AGENT, BROKER, OR “SURPLUS LINE” BROKER OR CONTACT THE CALIFORNIA DEPARTMENT OF INSURANCE, AT THE FOLLOWING TOLL-FREE TELEPHONE NUMBER: 1-800-927-4357.

6. IF YOU, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN TWO BUSINESS DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO BUSINESS DAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU CANCEL COVERAGE, THE PREMIUM WILL BE PRORATED AND ANY BROKER FEE CHARGED FOR THIS INSURANCE WILL BE RETURNED TO YOU.”

Date

Insured

SF 198230.2 73670 00741 D-1 (Effective January 1, 2008)