COMMERCIAL GENERAL LIABILITY APPLICATION

Insured Name

Other Entity/DBA(s)

AssocCorpIndividualJoint VentureLLCLLPLTDPartnershipS-CorpSole ProprietorNon-ProfitOther

Principal

Title

Direct Phone

Email

Audit Contact

Audit Title

Audit Direct Phone

Audit Email

Mailing Address

Physical Address

Business Phone

Mobile/Home

Fax

Company Email

Website

Federal ID Number/FEIN

License Number

Policy proposed effective date

Date established

How did you hear about us?
Web surfingAd in which publicationOther

Total number of employees

Full Time

Part Time

Armed

Unarmed

over age 65

under age 21

Average Length of Employment

Check limit of liability desired:
$300,000$500,000$1,000,000Excess/Umbrella

Do you anticipate using armed employees?
YesNo
If yes, please provide a listing of clients that armed
personnel are assigned and a description of their duties:

Are any employees trained to perform CPR?
YesNo
How many

a. Do you anticipate using dogs?
YesNo

b.Total number of dogs used

c. No. of dogs used with handlers

d. Without handlers

Do you enter into a standard contract with your clients?
YesNo

a. Are specific “post orders” developed for each guard site and approved by the client?
YesNo

b. Are changes to these “post orders” documented?
YesNo

What background do the principals of this organization have in the Security Industry:

Number of Supervisors:

Describe duties of Supervisors

Do they also perform guard duties?
YesNo

Are their hours billed to the client?
YesNo

Do you use any type of electronic or computerized supervision or guard monitoring system?
YesNo
if yes

Provide the names of your 10 largest revenue-producing clients, their locations and a description of duties

Guard Training: (Please provide the number of hours of training for each category)

Pre-Employment Screening

Credit Check.
YesNo

Driving Record
YesNo

Drug Testing
YesNo

Fingerprints
YesNo

Honesty Testing
YesNo

Personal Interview
YesNo

Physical
YesNo

Prior Employer
YesNo

Psychological Testing
YesNo

Firearm License Check.
YesNo

Additional Exposures

Firearm License Check
YesNo

If yes, do they carry their own insurance?

Do you enter into a sub-contractor agreement?
YesNo

Are the independent contractors retired or off duty law enforcement officers?
YesNo

Are they:
ArmedUnarmed

What is their annual cost

Does the insured provide any services other than Security Guard, Private Investigation or Alarm (i.e. janitorial services,
temporary staffing, valet services, training school, etc.)?
YesNo
If yes, please describe:

Prior General Liability Information

a. Please provide the following information for the prior 5 years, in addition to currently valued loss runs for the prior 4 years

Policy Term

Insurer

Premium

Payroll

Hours Billed

Deductible

Losses

Has any insurer cancelled or non-renewed your General Liability insurance over the past 5 years?
YesNo
If yes please explain

Employee Payscale (hourly)

Supervisors

Unarmed Guards

Armed Guards

Total Gross Receipts

Guard Services

Private Investigation Services

Security Consulting Services

Burglar/Fire Alarm Services

LIST ANNUAL PAYROLL SEPARATELY BY CATEGORY (Include independent contractors payroll not covered by other insurance)

OFFICE AND MANAGEMENT

CATEGORY

Clerical

Executive

Sales

Supervisory

GUARD SERVICES

CATEGORY

Airports

Banks/Office Buildings

Bars/Nightclubs

Bodyguard

Armored Cars

Auto Dealerships

Bus/Train Terminals

Cannabis Industry

Casinos

Churches/Places of Worship

Colleges/Universities

Concerts

Construction Sites

Convenience/Grocery Stores

Conventions/Trade Shows

Courier/Escort

Executive Protection

Fast Food Establishments

Golf/Tennis/Yacht Clubs

Government Contracts

Hospitals/Institutions

Hotels/Motels

Industrial (Factories,Warehouses)

Movies/Theaters

Museums/Galleries

Parking Garages

Patrol Cars

Restaurants

RESIDENTIAL

Apartments-Low Income/HUD

Apartments-Mid/High Income

Condominiums/Co-op’s

Gated Communities

RETAIL STORES

Inside/Surveillance

Parking Lots

Schools Elementary, High School

Security Consultation

Shopping Malls

Social Services/Clinics

Special Events

Sporting Events

Strike Duty

Traffic Control

Trucking Terminals

Waterfront/Piers/Marinas

Other (explain):

PRIVATE INVESTIGATION

Arson

Auto Repossessions

Credit or Pre-Employment

Domestic

Drug Testing

Insurance/Legal

Lie Detection

Livescan/Fingerprinting

Paper and Pencil

Process Serving

Shopping Service

Undercover

Other (explain)

BURGLAR/FIRE ALARMS - Separate alarm application must be completed if this coverage desired

Installation

Monitoring

SUPPLEMENTAL APPLICATION
(please complete this section if you provide services to any of these clients)

AIRPORTS
(Please list the airports being serviced and a description of the services provided and advise if it will include either passenger/baggage screening and or skycap services)

BODYGUARD/EXECUTIVE PROTECTION
Will these services involve protection of entertainers/athletes or other high profile individuals?
YesNo
Please provide a brief description of the services provided to these clients (i.e. estate security, 24 x 7 protection, etc.):

SCHOOLS/COLLEGES/UNIVERSITIES(Please provide a listing of these clients and a description of the services provided to these clients (i.e. vehicle patrol,
security in dormitories, security at special events, etc.))

HOSPITALS(Please provide a listing of these clients serviced and a description of the services provided (i.e. parking lot patrol,
security in the ER, patient restraint services, etc.))

HOTELS/MOTELS(Please provide a listing of the hotels/motels being serviced and provide a description of the services provided to these
clients (i.e. vehicle patrol, security at hotel lounge, student chaperone services, etc.))

RESIDENTIAL(Please provide a listing of the properties serviced, their locations and a description of the services provided to these
clients (vehicle patrol, gate guard, etc.))

SHOPPING MALL/RETAIL(Please provide a listing of these clients serviced and a description of the work provided)

SPECIAL EVENTS/SPORTING EVENTS(Please provide a listing of these clients and a description of the services provided to these clients)

OTHER OPERATIONS(Please provide a listing of these clients and a description of the services provided to these clients)

If MVR is poor, what corrective action is taken. Provide a brief explanation of the driver selection process (e.g. age, MVR review, proof of valid driver's license,drivers test, etc.)

NOTICE: ANY PERSON WHO, KNOWINGLY OR WITH INTENT TO DEFRAUD OR TO FACILITATE A FRAUD AGAINST ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR FILES A CLAIM FOR INSURANCE CONTAINING FALSE, DECEPTIVE OR MISLEADING INFORMATION MAY BE GUILTY OF INSURANCE FRAUD.
NOTICE TO ARKANSAS, LOUISIANA AND NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an Insurance Company for the purpose of defrauding or attempting to defraud the Company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any Insurance Company or agent of an Insurance Company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third degree.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with the intent to defraud any Insurance Company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
NOTICE TO MAINE APPLICANTS: It is a crime to provide false, incomplete or misleading information to an Insurance Company for the purpose of defrauding the Company. Penalties may include imprisonment, fines or a denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO OREGON APPLICANTS: Any person who, knowingly and with intent to defraud or facilitate a fraud against any insurance company or
other person, submits an application, or files a claim for insurance containing any false, deceptive, or misleading material information may be guilty
of insurance fraud.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with the intent to defraud any Insurance Company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO PUERTO RICO APPLICANTS: Any person who knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps, or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine of no less than five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000); or imprisonment for a fixed term of three (3) years, or both penalties. If
aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.
NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an Insurance Company for the purpose of defrauding the Company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTE: THIS APPLICATION MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN OR CEO OF THE APPLICANT ACTING AS THE AUTHORIZED AGENT OF THE PERSON(S) AND ENTITY(IES) PROPOSED FOR THIS INSURANCE. This request is for a cost-free, premium quotation only. In signing, I understand I am not obligated to purchase this insurance. This application shall not be binding unless and until confirmation by the company or its duly appointed representatives has been given, and that a policy shall be made, and then only as of the commencement date of said policy and in accordance with all terms thereof. The said applicant hereby covenants and agrees that the foregoing statements and answers are a just, full and true exposition, statement and explanation of all the facts and circumstances with regard to the risk to be insured, insofar as same are known to the applicant, and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the insured.

Signature Section

Principal, Owner or Officer Signature

Title

Date