Private Investigation General Liability (E & O) Application Section I - General InformationInsured's Name (including dba's) Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Physical Address Same as previous Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Name Title PhoneCellEffective Date Desired MM slash DD slash YYYY Check One Individual Partnership Corporation Other Limit of Liability DesiredOccurenceAggregateEmail Address Date Company Established MM slash DD slash YYYY What background do the principals of this organization have in the Investigative Industry?Federal ID Number (FEIN) License Number ****Your liability insurance defines Independent Contractors as workers who carry their own license and their own liability insurance. All other employees who are 1099 or W2 are considered "on the payroll" and their salaries should be included on the next page.Does applicant subcontract work to others? Yes No Do sub-contractors maintain their own insurance? Yes No Are Certificates of Insurance required from subcontractors? Yes No Do you require subcontractors to name you as an additional insured on their policies? Yes No Annual Sub-Contractor Cost: Does your firm provide any type of security guard or alarm operations? Yes No If "Yes", please explainPlease provide a list of your types of clients, along with a description of services:Section II - OperationsTotal number of Owner(s):Number of Owners performing investigation(s)Number of owners that work 250 hours or less per year:Number of owners that work 251 to 450 hours per year:Number of owners that work 451 hours or more per yearNumber of employees performing or involved with investigationsNumber of investigation employees that work 250 hours or less per yearNumber of investigation employees that work 251 hours to 450 hours per yearNumber of investigation employees that work 451 hours or more per yearAnnual Corporate RevenueTotal Employee PayrollEmployee Training Consists of Written Manual Report Writing Firearms CPR Powers of Arrest On the Job Other Pre-Employment screening procedures for employees (check all that apply) Driving Record (MVR) Background Check Drug Screening Fingerprint Check Personal References Other Section II - Operations (Continued)*Please indicate % of operations (must be 100%) Private InvestigationAccident Investigations/Reconstruction**Asset SearchesBackground InvestigationsBank & Accounting FraudChild Recovery/CustodyComputer CrimeCredit/Pre-EmploymentDomestic (Matrimonial/Divorce)EnvironmentalExecutive Protection**Expert WitnessFire / ArsonInsurance InvestigationsLegal InvestigationsMissing Persons / HeirsProcess ServingRecord ServicesRepossessionsShopping Services**Skip Tracing / CollectionsSurveillance / ElectronicWC / Fraud InvestigationsWhite Collar CrimesOther**Security Consulting**Construction DesignCriminalData / Computer SecurityKidnap / TerroristSeminars / LecturesTerrorismThreat AssessmentsOtherLie DetectionPaper / Pen & PencilPolygraphPsychological Stress EvaluatorOtherTraining# Firearms Training-Classroom (students/yr)# Security-Classroom (students/yr)# Firearms Training-Firing Range (students/yr)# Other** (students/yr)**Please refer to Section III for a further explanation of operationsSection III - Description of Operations (If Applicable)Accident Investigations/Reconstruction - Please describe all operations below: Any fault assessment? Yes No Executive Protection - Please describe all duties performed below:Any athletes, celebrities, or entertainers? Yes No Expert Witness - Do you provide court testimony as an expert for cases that you are NOT investigating? Yes No If "Yes", please describe all operations/duties performedProvide ResumeMax. file size: 360 MB.Fire/Arson - Please describe all operations/duties performed below:Any cause of origin? Yes No Shopping Services - Please describe events, locations and duties:Security Consulting - Please describe clients, scope of services performedProvide a sample contractMax. file size: 360 MB.Other - Please describe all operations/duties performed:Section IV - Current Insurance InformationCurrent Carrier Inception Date MM slash DD slash YYYY Expiration Date MM slash DD slash YYYY PremiumDeductibleLimit of Liability: Occurrence Form? Yes No Have there been any claims or lawsuits in the past 5 years? Yes No If "yes", please attach statement of losses.Max. file size: 360 MB.Do you anticipate any future claims/losses? Yes No SignageApplicant Name: Applicant Title Date MM slash DD slash YYYY Signature
