Security Guard Services CommentsThis field is for validation purposes and should be left unchanged.Section I - General InformationThis field is hidden when viewing the formAgencyIDThis field is hidden when viewing the formForm NameCompany Name(Required)DBAMailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Code Physical Address Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Code Contact(Required) First Last TitlePhoneCellFaxEmail Address(Required) Enter Email Confirm Email Effective Date Desired: MM slash DD slash YYYY Business Type (Select One) Individual Partnership Corporation Other Federal ID(FEIN)License NumberHow long have you been 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.Client #1ServicesClient #2ServicesClient #3ServicesClient #4ServicesClient #5ServicesAre the majority of your clients under contract? Yes No How many include hold harmless clauses?(Put 100 if all contracts hold harmless clauses)Please enter a number from 0 to 100.Is workers’ compensation coverage currently in force? Yes No Please ExplainSection II - OperationsPlease list the names, position, percentage of ownership, and background of all parties involved in the business.Name #1PositionOwnerPartnerShareholderPercentage of OwnershipPlease enter a number from 0 to 100.Background in Security BusinessName #2PositionOwnerPartnerShareholderPercentage of OwnershipPlease enter a number from 0 to 100.Background in Security BusinessName #3PositionOwnerPartnerShareholderPercentage of OwnershipPlease enter a number from 0 to 100.Background in Security BusinessName #4PositionOwnerPartnerShareholderPercentage of OwnershipPlease enter a number from 0 to 100.Background in Security BusinessWill 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 Select AllOther TrainingPre-Employment screening procedures for employees (check all that apply): Driving Record (MVR) Drug Screen Fingerprint Check Personal References Psychological Test Other Select AllOther ScreeningNumber 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 Payroll (UA)Armed Payroll (A)UA - Airports (non-public)**A - Airports (non-public)**UA - Airports (public)**A - Airports (public)**UA - Armored CarA - Armored CarUA - BanksA - BanksUA - Bounty Hunting/Bail EnforcementA - Bounty Hunting/Bail EnforcementUA - Car DealershipsA - Car DealershipsUA - ChurchesA - ChurchesUA - Construction or Demolition SitesA - Construction or Demolition SitesUA - Convention/Trade ShowsA - Convention/Trade ShowsUA - Criminal Detention Centers**A - Criminal Detention Centers**UA - Executive ProtectionA - Executive ProtectionUA - Fast Food EstablishmentsA - Fast Food EstablishmentsUA - Federal Government ContractsA - Federal Government ContractsUA - Gated Communities/RetirementA - Gated Communities/RetirementUA - Government-Owned Housing**A - Government-Owned Housing**UA - Hotels/MotelsA - Hotels/MotelsUA - Industrial (Factories, Warehouses, etc.)A - Industrial (Factories, Warehouses, etc.)UA- Institutions (Hospitals, Clinics)A - Institutions (Hospitals, Clinics)UA - Liquor Establishments (Bars, Taverns, Etc.)A - Liquor Establishments (Bars, Taverns, Etc.)UA - Local & State ContractsA - Local & State ContractsUA - Middle/High Income Housing**A - Middle/High Income Housing**UA - Museums/GalleriesA - Museums/GalleriesUA - Office BuildingsA - Office BuildingsUA - Patrol CarsA - Patrol CarsUA - RestaurantsA - RestaurantsUA - Retail Stores (Parking Lots, Outside Perimeter)**A - Retail Stores (Parking Lots, Outside Perimeter)**UA - Retail Stores *Inside, Shoplifting, Door Duty)**A - Retail Stores *Inside, Shoplifting, Door Duty)**UA - SchoolsA - SchoolsUA - Special Events (Sports, Concerts, Etc)**A - Special Events (Sports, Concerts, Etc)**UA - Strike DutyA - Strike DutyUA - Traffic ControlA - Traffic ControlUA - Transport/Courier OperationsA - Transport/Courier OperationsUA - Trucking TerminalsA - Trucking TerminalsUA - Waterfront/Piers/MarinasA - Waterfront/Piers/MarinasUA - Other**A - Other**Private Investigations Unarmed Payroll (UA)Private Investigations Armed Payroll (A)UA - Executive Protection/Bodyguard Service**A - Executive Protection/Bodyguard Service**UA - Insurance, Legal, Credit, Pre-EmploymentA - Insurance, Legal, Credit, Pre-EmploymentUA - Lie Detection, PolygraphA - Lie Detection, PolygraphUA - Process ServerA - Process ServerUA - Security Consultant**A - Security Consultant**Total UnarmedTotal Armed**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 Name(Required) First Last Applicant TitleDate MM slash DD slash YYYY Signature
