Private Investigation Agency Quote

Note: AlI Questions Must Be Answered

Business Type
New BusinessRenewal

Line of Business
General LiabilityExcess

GL Policy Number - Renewal Only

GL Effective Date

Interested in
Property (Attach reg. forms: ACORD 125 and 140)Inland Marine (Attach req. forms: ACORD 125, 146, and 148)

Insured Company Name

DBA(s)

IndividualAssocCorpJoint VentureLLCLLPPartnershipC-corpS-CorpSole ProprietorTrustNon-ProfitOther

Mailing Address

Physical Address

County

NAICS/SIC Code

Business Phone

Fax

Company Email

Website

Federal ID Number/FEIN

License Number

Principal

Title

Mobile

Email

Audit Contact

Audit Title

Audit Direct Phone

Audit Email

A. Has the principal(s) of this firm previously operated a similar firm under a different name?
YesNo
If yes, please provide the former name

Policy proposed effective date

Date established

How did you hear about us?
Internet SearchSocial MediaEmailWord of Mouthother

Check limit of General Liability desired
$100,000$300,000$500,0001,000,000

BASIC EMPLOYMENT INFORMATION

Total No. of employees

Full time

Part time

Investigators

Consultants

What does your pre-employment screening process include?
Criminal BackgroundDriving RecordDrug ScreenFingerprint CheckPersonal interviewPrior EmploymentPsychological TestHonesty Testing

Regarding your Employees' Training: (please provide the number of hours of training for each category)

Classroom training

Total number of annual training hours

Other, describe

On-the-job training

OPERATIONS INFORMATION

Does your firm provide any type of security guard operations (i.e.: executive protection, standing guards, security patrol, bodyguard work, etc.)?
YesNo

If Yes, you must switch to the BrownGuard Liability Application for Private Security Agencies instead of this application.

Indicate percent of operations

provide details

Any other operations i.e.: alarm, fugitive recovery, etc.)

Do you collect, transmit, provide, acquire or scan any biometric data from others? (Biometric data can be defined as retina/iris scans, fingerprint, voiceprint or scan of hand or face geometry)
YesNo
If yes, please advise if you collect, transmit, provide, acquire or scan it and identify the type of biometric exposure (facial recognition, fingerprints, iris scanning, etc.):

Do you have a written biometric policy in place that complies with the regulations of the states you operate in?
YesNo

List your (5) largest clients

What background do the principals of this organization have in the Investigative/Security Consultation Industry?

Annual gross receipts

Payroll

Sub-contractor expense

Are sub-contractors' Certificates of Insurance on File?
YesNo

Indicate % of operations (A+B+C CATEGORIES MUST TOTAL 100%)

A.) PRIVATE INVESTIGATION

B.) SECURITY CONSULTATION

Firearms Training (this is if you provide these operations - not regarding your own certitication)

C.) LIE DETECTION

PRIOR GENERAL LIABILITY INFORMATION

a. General Liability insurer and claims history for past five years (Even if the re are no losses, please provide insurer history)

Policy No

Policy Term

Insurer

Premium

Limits/Liability

Revenue

Deductible

Losses

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

COMMERCIAL EXCESS APPLICATION (only if applicable)

Expiring Excess policy number (renewal only)

Effective date

Check limit of General Liability desired
$100,000$2000,000$3000,0004000,000$5000,000other

Underlying Insurance (Please provide us with copies of the underlying declarations pages and 4 years of currently valued loss runs for policies not written through our office)

Genera Liability

Automobile Liability

Employers LIability (Workers' Comp)

Underlying Auto Information (Required if scheduling auto within excess)

Vehicles

Trucks(Light)

Trucks(Medium)

Trucks(Heavy)

Trucks(Ex. Heavy)

Private Pessenger

Buses

Total Insurance Value for Auto Fleet

Uses

How are venicles used?

Do autos go outside the Us

YesNo

Are any explosives. flammables or other dangerous cargo hauled

YesNo

dAre passengers carried for a fee?

YesNo

Drivers

Are emplovees allowed to use their personal vehicles for business use?

YesNo

If yes, does the insured confirm that minimum limits of personal auto insurance is carried?

YesNo

Can family members drive company vehicles?

YesNo

Does the underlying Insurance include Hired Non-Owned Auto?

YesNo

Are MVRs checked for all drivers?

YesNo

Are MVRs regularly checked during their employment?

YesNo
If yes, how often

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