Alarm & Monitoring Quote – Forms

Section I - General Information

Applicant Legal Name (Including dba's):(Required)

Name to Appear on Company License(Required)

Owner(Required)

Contact Person/Title

Phone(Required)

Fax

Email Address(Required)

Mailing Address

Physical Address

Same as previous

Company License Numbers(s)

Check One(Required)

Individual

Partnership

Corporation

Other

Number of years in business:

FEIN #

Effective date desired

from

Limits of Liability

Occurrence

Products/Completed Operations

Aggregate

Section II - Total Estimated Annual Revenue

Estimated 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 owner

Annual 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 Information

Carrier

Expiration Date

General Aggregate

Occurrence

Claim History (Please provide 5 years current valued loss runs):

Prior Year

1st Prior Year

2nd Prior Year

3rd Prior Year

4th Prior Year

Premium

Section IV - Operations

Do You Operate in any Other States?

Yes

Please List

Operations are(%):

% Fire Alarm

% Burglar Alarm

% Combination

% Home Theater

% Medical Alert

% Temp. Control

% Closed Circuit

Preconstruction 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.**

Description

Tract homes, Condos, Townhouses

Custom Homes

Total number of customers:

Name under contract:

Do you install alarm or service safety equipment in:

Nursing Homes

Yes

Medical Facilities

Yes

Correctional Facilities

Yes

Detection Facilities

Yes

If yes, what percentage of your total work is designated to this?

Does your company do its own monitoring?

Yes

If no, please provide the name of monitoring company detection facilities:

Section V - Alarm Response

Do you provide security/patrol response to your customers if and when Police/Fire/EMT's do not respond?

Yes

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

If you have a contract with the security company, is either part holding the other harmless/providing indemnification?

Yes

If yes, provide details:

Do any employees or subcontractors carry firearms?

Yes

Signage

Completed By:

Title

Date

Signature

Alarm Liability Application