General Liability Insurance Application

General Information

Name

Physical address

Mailing address

Effective date requested

Date current coverage expires

Contact Person

Telephone #

Email address

Date established

FEIN #

License #

Website

Have you ever operated under any other name?
YesNo

Name of entity

Industry experience

Please list any non-security related operations

Do you subcontract work to others?
YesNo

What operations are subcontracted?

What is the payroll for the subcontracted work?

Do you require GL or WC certificates from subcontractors?
YesNo

Do the subcontractors carry GL limits equal to or greater than the limits requested on this application?
YesNo

Are you named as an additional insured on all subcontractor policies?
YesNo

If either of the above questions are “No,” is your subcontracted payroll included in your total payroll estimate?
YesNo

What does your pre-employment screening process include?
Criminal BackgroundDriving RecordDrug ScreenFingerprint CheckPolygraphPrior Employment ContactedPsychological TestOther

Do you have a new employee training program?
YesNo
Please describe

No. of employees

Full time

Part time

Armed

Unarmed

Do you employ any off duty police officers?
YesNo

Please describe your gun control program if employees are armed

Do your operations involve the use of drones, unmanned aircraft or robots?
YesNo
If “Yes,” please explain

Do your security officers have power of arrest or detention authority?
YesNo
Please describe

Do you sell products?
YesNo
If “Yes,” what type of products do you sell?

Do you operate a training school for guards that are not your employees?
YesNo

Do you provide any alarm installation or monitoring service?
YesNo
If “Yes,” please also submit the Alarm/Electronic Security application (SGL 201).

Do you enter into a standard contract with clients?
YesNo

Percentage under contract %

Coverage & Limits Section

Limits requested
$1M/$2M$1M/$3M$1M/$4M$1M/$5MOther

Deductible requested
$0$1,000$2,500$5,000

Do you require any of the below coverages to fulfill client contract requirements? Please note that some of these coverages may require additional premium.
Additional InsuredEmployee Benefits LiabilityHired/Non-owned AutoPer Project AggregatePrimary WordingStop GapWaiver of Subrogation

Do you require excess/umbrella coverage?
YesNo
If “Yes,” what limit is needed?

If excess/umbrella coverage is required please complete the excess portion of the application

Security Guard Section

Estimated annual security guard payroll.

Do you use canines?
YesNo

Do you have a written procedure for reporting incidents?
YesNo

Are security officers provided with any of the following equipment for use in their duties?

Aerosol chemicals
YesNo

Flashlights
YesNo

Handcuffs
YesNo

Night Stick – Standard
YesNo

Do you use mobile equipment such as, but not limited to, golf carts?
YesNo

Please provide percentage breakdown for all security guard and armored car operations below. Some operations may require further explanation.

Operations

Airports

Armored Cars

Auto Dealerships

Banks

Bars/Nightclubs/Taverns

Cannabis Industry

Casinos

Churches

Hotels/Motels

Ind/Warehouses/Factories

Liquor Stores

Movie Theaters

Museums/Galleries

Parking Garages

Restaurants

Security Consulting

Apt.Low Income/HUD/Section8Housing

Apt.Mid/High Income Housing

Bodyguard/Exec Protection

Residential – HOA/Condos/Townhomes

Colleges/Universities Churches

High School/Lower Grades

Hospitals/Medical Facilities

Special Events/Sporting Events

Construction Sites

Convenience Stores

Golf Clubs

Government Contracts

Convention/Trade Shows

Concerts

Fast Food Restaurants

Strike Duty/Protests

Traffic Control

Transportation Terminals

Shipping Ports/Piers/Marinas

Utilities–Water/Electrical/Nuclear

Other

Detective/PI Section

Estimated annual Detective/Private Investigator Payroll

Do your final reports include recommendations or an appropriate course of action?
YesNo

If involved in background/credit checks, are all employees trained in fair credit reporting act compliance?
YesNo

Does your firm have procedures in place to protect against clerical errors?
YesNo

Does your firm attach standard disclaimers to all completed reports?
YesNo

Please provide percentage breakdown for all detective and private investigator operations below. Some operations may require further explanation.

Operations

Arson Investigation

Auto Repossessions

Bail Bonding

Bounty Hunting

Civil/Criminal Investigation

Corporate/Trademark Infringement

Missing Person Searches

Computer Investigations

Polygraph / Lie Detection

Domestic

Drug Testing

Fraud Auditing

Insurance Investigation

Legal

Process Serving

Psychological Evaluation

Undercover

Pre-Employment Screening/Credit Checks

Other

Policy Information

Please provide prior year policy information below.
Please attach five (5) years of currently valued loss history

Category

Carrier

Current Year

First Prior

Second Prior

Third Prior

Fourth Prior

Premium

Current Year

First Prior

Second Prior

Third Prior

Fourth Prior

Payroll

Current Year

First Prior

Second Prior

Third Prior

Fourth Prior

Deductible

Current Year

First Prior

Second Prior

Third Prior

Fourth Prior

Incurred Losses

Current Year

First Prior

Second Prior

Third Prior

Fourth Prior

Have any claims been made over the last five (5) years?
YesNo

Do you have any knowledge of incidents that could lead to a claim in the future?
YesNo
If “Yes,” please explain

Has your insurance been cancelled, declined or non-renewed in the last three (3) years?
YesNo
If “Yes,” please explain

Total number of clients

Please list your six (6) largest clients:

Additional Operations Information

Some operations indicated earlier need additional explanation. If you are involved in any of the below listed operations,
please provide additional details

Airports

Please provide a list of any airports where you provide services.

Do you provide assistance to passengers with disabilities?
YesNo

Do you provide baggage screening services?
YesNo

Do you provide screening of cargo or take custody of any cargo?
YesNo

Do you provide passenger or personnel screening?
YesNo

Executive Protection/Bodyguarding

Do you provide security for any public figures such as celebrities, athletes, entertainers or politicians?
YesNo
If “Yes,” please describe for who and what services are provided.

Special Events

If you provide services at any special events including but not limited to sporting events, concerts, conventions, trade shows, parties and/or weddings, please list the events below

Do you security check the public entering the event?
YesNo

Are you responsible for crowd control?
YesNo

What is the maximum number of people attending the events where you provide security?

Apartments/Residential

Please list the name of your apartment complexes including addresses

Name of Apartment

Address

Is your company involved in providing security services at low income, government owned, HUD or Section 8 housing?
YesNo

Schools & Colleges

Please provide a list of any schools or colleges where you provide security services.

Do you physically check students entering buildings?
YesNo

Do you have any work at dormitories or student housing?
YesNo

Do security officers working at these locations receive site specific pre-screening and training?
YesNo

Restaurants

Please provide a list of any restaurants where you provide security services

Name of Restaurant

Address

Hours of Operation

Do any serve alcohol past 11PM?
YesNo

Do any have a dance floor and/or live entertainment?
YesNo

Fraud Warnings
Warning – Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance
containing any false information, or conceals for purposes or misleading information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime.
Alabama – 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 restitution fines or confinement in prison, or any
combination thereof.
Arkansas – 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.
Colorado – 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 for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department
of Regulatory Agencies.
District of Columbia – 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. [DC Code]
Florida – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim containing any
false, incomplete, or misleading information is guilty of a felony of the third degree.
Kentucky – Any person who knowingly and with 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.
Louisiana – 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.
Maine – It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
Maryland – Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
New Jersey – Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
New Mexico – 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 civil fines and criminal penalties.
New York – 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.
Ohio – 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.
Oklahoma – 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.
Pennsylvania – 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 subjects such person to criminal and civil
penalties.
Rhode Island – 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 of a crime and may be subject to fines and confinement in prison.
Tennessee – 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.
Virginia – 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.
Washington – 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.
West Virginia – 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.

Signature Section

Notice to applicants: this application must be completed in full as the quote will be based solely on the information provided.
Any person who knowingly and with 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 insurance act, which is a crime. By signing this application, the signor warrants that
to their best knowledge all information given is true and accurate.

Principal, Owner or Officer Signature

Title

Date