Section I - Company Profile

Insured's Name (including dba’s)

Mailing Address:

City:

State:

Zip:

Physical Address:

City:

State:

Zip:

Branch Locations:

Contact:

Title:

Phone:

Cell:

Fax:

Effective Date Desired:

(Check one) Individual:

Partnership:

Corp:

Other:

License Number(s):

Email Address:

How long in the Security business?

How long under this name?

Has the applicant operated under any other name?

Yes
No

If yes, please identify:

FEIN:

ANNUAL PAYROLL PROJECTIONS
Classifications	Code	Part-Time Employees	Full-Time Employees	Payroll
Alarm Installation	7600
Alarm Monitoring	8901
Clerical / Office Staff	8810
Executive Officers	8809
Fire Extinguisher	8107
Fire Suppression	5183
Outside Sales	8742
Private Investigators	7720
Security Officers	7720
Other:

Section II – General Information

Does applicant handle any explosives, hazardous waste, asbestos, or radioactive material?	Yes	No
Does applicant supply or furnish any workers to others on a permanent or temporary basis? Temporary or alternate staffing or PEO?	Yes	No
Does applicant engage in agricultural harvesting for others?	Yes	No
Is the applicant a professional sports team or employ professional athletes?	Yes	No
Does the applicant have any Federal exposures such as US L&H or Jones Act?	Yes	No
Does the applicant own, operate, charter, maintain, rent, use or lease aircraft?	Yes	No
Does the applicant employ any member of a crew or master of any vessel in navigable waters?	Yes	No
Is there group transportation or any delivery operations?	Yes	No
Is there a formal safety program in operation?	Yes	No
Is the applicant’s workforce made up of more than 10% volunteers?	Yes	No
Does the applicant provide a Health Insurance Plan for all employees?	Yes	No
Has the applicant been insured for workers' compensation for at least 2 years?	Yes	No
Has the applicant’s workers' compensation ever been cancelled or non-renewed for nonpayment, fraud, misrepresentation or failure to report compensable accidents?	Yes	No
Any work performed underground or over 15 feet?	Yes	No
Any work performed on barges, vessels, docks, or bridge over water?	Yes	No
Is applicant engaged in any other type of business?	Yes	No
Any seasonal employees?	Yes	No
Any employees under 16 years of age?	Yes	No
Are sub-contractors used? (If yes, please give % of sub-contractors used)	Yes	No
Is applicant a municipal, county, or state police department?	Yes	No
Any work for correctional department, jail, or penitentiary employees?	Yes	No
Any work for juvenile probation officers / attendants for juvenile homes?	Yes	No
Any National Guard, Forest Rangers, or Game & Fish Wardens?	Yes	No
Any hunting & fishing guides or border patrol officers?	Yes	No
Any private investigation involving bounty hunting or bail bonding?	Yes	No
Any armored car services?	Yes	No
Any officers under 18?	Yes	No
Any officers have duties as traffic control on major traffic areas / highways?	Yes	No
Any public housing security, fast food security, or 24-hour convenience store security?	Yes	No
Any armed officers not licensed by authorities to carry a weapon?	Yes	No
Any bodyguard service?	Yes	No
Any work for nuclear or petro-chemical plants?	Yes	No
Any alarm response in connection with alarm monitoring?	Yes	No
Any work for refineries or offshore oil / rigs?	Yes	No
Any private investigation work involving repossession work?	Yes	No

Please provide a full description of your operations:

If providing security guard services, please provide:

% Unarmed
% Armed

Executive Officer Information: (Please advise if officers are to be Included or Excluded)
Name	Title	Ownership%	Duties	INCL or EXCL	Payroll

Previous Carrier Information: Check here if none
Insurance Carrier	Policy Term	Premium	Losses

Section III – Additional Information

In order to secure a Workers’ Compensation quote for your firm, the additional following information is needed:

1. Copies of your latest two quarterly Federal 941 Summary Reports.
2. Copies of the Declarations and Classifications pages of your current Workers’ Compensation or Occupational Accident policy
3. Copies of your loss runs for the latest four year period
4. Copy of your current experience modifier sheet (if experience rated)
5. If no prior Workers’ Compensation or Occupational Accident policy, please provide a statement on your letterhead detailing the employee injury accidents your firm has experienced over the past 3 years. If none, please state so.

**** If you have had no prior Workers’ Compensation coverage, please disregard items #2-4.

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 Workers Compensation Application

Section I - Company Profile

Section II – General Information

Section III – Additional Information