Security Industry 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 ContactTitlePhoneCellFaxEmail Address Effective Date Desired: MM slash DD slash YYYY Select One Individual Partnership Corporation Other Federal ID(FEIN)License NumberHow long in the Security business?How long under this name?Has the applicant operated under any other name? Yes No Please IdentifyApplication Classification:% Security Service% Investigations% Consulting% Alarm Service & MonitoringLimit of Liability DesiredEach Occurrence:AggregateIn regards to your clients, do you assume any duties not related to security? Yes No Please Explain BelowPlease provide a list of your (5) five largest clients, along with a description of services.Are the majority of your clients under contract? Yes No How many include hold harmless clauses?(Put 100 if all contracts hold harmless clauses)Is workers’ compensation coverage currently in force? Yes No Please ExplainSection II - OperationsName of Owner(s), Partner(s) and Shareholder(s), their percentage of ownership and background in this industry:Will the principals perform guard/investigative operations? Yes No Please describe duties of supervisors:Average number of officers per supervisor:Employee training consists of: CPR Firearms On the Job Powers of Arrest Report Writing Written Manual Other Pre-Employment screening procedures for employees (check all that apply): Driving Record (MVR) Drug Screen Fingerprint Check Personal References Psychological Test Other OtherNumber of hours billed to client(s) annually:UnarmedArmedNumber of Officers:Full TimePart TimeUnarmedArmedDo you use any golf carts for patrol? Yes No If yes, are they equipped with lights? Yes No Will the public be transported? Yes No Are driving records checked? Yes No Do you anticipate using dogs? *Must be leashed not to extend 6 ft. Yes No Number of dogs used with handlers:Number of dogs without handlers:Do any of your officers use tasers in their operations? Yes No Any operations performing security services where jewelry, money, securities or furs are present? Yes No Of what professional associations are you a member?Section III - Projected Annual Payroll****Your liability insurance carrier 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 table below.Based on the above definition, do you have any independent contractors? Yes No Please give their total salaries:Unarmed PayrollArmed PayrollAirports (non-public)**Airports (non-public)**Airports (public)**Airports (public)**Armored CarArmored CarBanksBanksBounty Hunting/Bail EnforcementBounty Hunting/Bail EnforcementCar DealershipsCar DealershipsChurchesChurchesConstruction or Demolition SitesConstruction or Demolition SitesConvention/Trade ShowsConvention/Trade ShowsCriminal Detention Centers**Criminal Detention Centers**Executive ProtectionExecutive ProtectionFast Food EstablishmentsFast Food EstablishmentsFederal Government ContractsFederal Government ContractsGated Communities/RetirementGated Communities/RetirementGovernment-Owned Housing**Government-Owned Housing**Hotels/MotelsHotels/MotelsIndustrial (Factories, Warehouses, etc.)Industrial (Factories, Warehouses, etc.)Institutions (Hospitals, Clinics)Institutions (Hospitals, Clinics)Liquor Establishments (Bars, Taverns, Etc.)Liquor Establishments (Bars, Taverns, Etc.)Local & State ContractsLocal & State ContractsMiddle/High Income Housing**Middle/High Income Housing**Museums/GalleriesMuseums/GalleriesOffice BuildingsOffice BuildingsPatrol CarsPatrol CarsRestaurantsRestaurantsRetail Stores (Parking Lots, Outside Perimeter)**Retail Stores (Parking Lots, Outside Perimeter)**Retail Stores *Inside, Shoplifting, Door Duty)**Retail Stores *Inside, Shoplifting, Door Duty)**SchoolsSchoolsSpecial Events (Sports, Concerts, Etc)**Special Events (Sports, Concerts, Etc)**Strike DutyStrike DutyTraffic ControlTraffic ControlTransport/Courier OperationsTransport/Courier OperationsTrucking TerminalsTrucking TerminalsWaterfront/Piers/MarinasWaterfront/Piers/MarinasOther**Other**Private InvestigationsExecutive Protection/Bodyguard Service**Executive Protection/Bodyguard Service**Insurance, Legal, Credit, Pre-EmploymentInsurance, Legal, Credit, Pre-EmploymentLie Detection, PolygraphLie Detection, PolygraphProcess ServerProcess ServerSecurity Consultant**Security Consultant**TotalTotal**Please refer to Section IV for a further explanation of operationsAverage Hourly Wage (Full Time)Average Hourly Wage (Part Time)Annual Corporate Revenue (Full Time)Alarm Operations Estimated RevenueSection IV - Description of OperationsAirport Work- Please describe all operations/duties performed:Apartment Work- Please describe duties. If any government-owned, please provide list of addresses:Criminal Detention Centers- Please describe all operations/duties performed:Retail Work- Please describe types of stores, duties, and hours that guard(s) are on duty:Special Events- Please describe events, locations and duties:Bodyguard Work - Please describe dutiesAny athletes, celebrities or entertainers? Yes No Security Consulting- Please describe consulting clients and scope of services provided:Other-Please describe all operations/duties performed:Section V - Current Insurance InformationCurrent Carrier:inception_date MM slash DD slash YYYY expiration_date MM slash DD slash YYYY PremiumDeductibleLimit of LiabilityOccurrence Form? Yes No Has any company cancelled or declined to renew liability insurance? Yes No Please explain belowDo you require staff to report all unusual incidents to management? Yes No Have there been any claims or lawsuits in the past 5 years? Yes No Please explain belowPlease attach five years of company loss runsMax. file size: 360 MB.Do you have any knowledge of any incidents which may give rise to a future claim? Yes No Please Explain BelowNOTICE 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.SignageApplicant NameApplicant TitleDate MM slash DD slash YYYY Signature
