Alarm Liability Application Section I - General InformationApplicant Legal Name (Including dba's):(Required)Name to Appear on Company License(Required)Owner(Required)Contact Person/TitlePhone(Required)FaxEmail Address(Required) Mailing Address mailing_address city StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific state zip Physical Address Same as previous location_address city-loc StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific state-loc zip-loc Company License Numbers(s)Check One(Required) Individual Partnership Corporation Other Number of years in business:FEIN #Effective date desiredfrom MM slash DD slash YYYY to MM slash DD slash YYYY Limits of LiabilityOccurrenceProducts/Completed OperationsAggregateSection II - Total Estimated Annual RevenueEstimated Revenue for next 12 months (not including monitoring revenue):Estimated monitoring revenue:% of revenue generated by jobs subcontracted to insured companies:Number of technicians not including ownerAnnual payroll for technicians not including clerical/admin/owner(s):Revenue for previous 12 months:Owner(s) payroll (only if Field Work is performed by owner(s))Section III - Current Insurance InformationCarrierExpiration Date MM slash DD slash YYYY General AggregateOccurrenceClaim History (Please provide 5 years current valued loss runs):Prior Year1st Prior Year2nd Prior Year3rd Prior Year4th Prior YearPremiumSection IV - OperationsDo You Operate in any Other States? Yes No Please ListOperations are(%): % Fire Alarm% Burglar Alarm% Combination% Home Theater% Medical Alert% Temp. Control% Closed CircuitPreconstruction Wiring/Conduit% Other Client Base:% Commercial% Apartments% Industrial% Single Family% Institutional% Condos% New Home Builders** Please describe the type of work being done for New Home Builders i.e. tract homes, condominiums, custom homes. A "tract home" is defined as a development of five or more individual and freestanding houses which share common or similar design elements, floor plans, blueprints and/or architectural details, and/or which are constructed at the same time, or consecutively, on the same parcel, adjacent parcels, or parcels so located within one geographic area to be considered a single project.**DescriptionTract homes, Condos, TownhousesCustom HomesTotal number of customers:Name under contract:Do you install alarm or service safety equipment in:Nursing Homes Yes No Medical Facilities Yes No Correctional Facilities Yes No Detection Facilities Yes No If yes, what percentage of your total work is designated to this?Does your company do its own monitoring? Yes No If no, please provide the name of monitoring company detection facilities:Section V - Alarm ResponseDo you provide security/patrol response to your customers if and when Police/Fire/EMT's do not respond? Yes No If yes, are the responders employees, or hired/contracted for this service?Fully describe alarm response procedures:If responders are not employees, do you have a written contract with the security company that provides the response? Yes No If you have a contract with the security company, is either part holding the other harmless/providing indemnification? Yes No If yes, provide details:Do any employees or subcontractors carry firearms? Yes No SignageCompleted By:TitleDateSignature
