Workers Compensation Section

Insured Name

Effective Date From

Effective Date To

Federal ID Number

NCCI/State ID Number

List payroll by each State you are doing business in.Attach separate sheet if more than three states

State 1

Security Officers

Administration

Sales

Executive Officers

Investigators

Central Station Operators

Electronic Security Techs

State 2

Security Officers

Administration

Sales

Executive Officers

Investigators

Central Station Operators

Electronic Security Techs

State 3

Security Officers

Administration

Sales

Executive Officers

Investigators

Central Station Operators

Electronic Security Techs

Policy Year 1

Insurance Company 1

Experience Mod 1

Premium 1

Policy Year 2

Insurance Company 2

Experience Mod 2

Premium 2

Policy Year 3

Insurance-Company 3

Experience Mod 3

Premium 3

Please list your 8 largest clients based on revenue:

A

Name of Client

Annual Revenue

# of Sites

B

Name of Client

Annual Revenue

# of Sites

C

Name of Client

Annual Revenue

# of Sites

D

Name of Client

Annual Revenue

# of Sites

Employee pay scale (Hourly)

a. Supervisors(Hourly)

Minimum

Maximum

Average

b. Unarmed Guards(Hourly)

Minimum

Maximum

Average

c. Armed Guards

Minimum

Maximum

Average

Has any company canceled or declined to renew?
YesNo
If yes, please explain below:

Maximum number of employees at any one WORKSITE during any shift or block of work time:

A Worksite is considered a separate worksite if security station is separated by more than 1,000 vertical feet

Do you perform work at any "landmark" locations as defined below
YesNo
A Landmark is a building, district, site, structure, or object, officially recognized by the US government for its historical significance. Landmarks are designated by the US
Secretary of the Interior because they are Sites where events of national historical significance occurred; Places where prominent Americans lived or worked; Icons of
ideals that shaped the nation; Outstanding examples of design or construction; Places characterizing a way of life; or Archeological sites able to yield information

Do you perform work in any of the following cities:
New York CityChicagoWashington DCBostonSan FranciscoLos Angeles

Does your firm perform security services at either of the following:

a) Nuclear Power Plants
YesNo

b) Chemical, Explosives or Weapons Manufacturers
YesNo

Has a law enforcement agency or municipality hired your firm to act as police officers, sheriffs, constables or correction officers?
YesNo

Do you provide any type of PDR, SWAT, ERS, Extraction or Repatriation services?
YesNo

Does your company have the following:

a) A written safety policy and goals?
YesNo

b) Safety and training programs?
YesNo

c) A written drug and alcohol policy?
YesNo

e) A designated safety coordinator?
YesNo

e) A designated safety coordinator?
YesNo

f) Prompt reporting of all employee injuries?
YesNo

g) A formal accident review and investigation program?
YesNo

h) Employee involvement in inspection/safety committees?
YesNo

i) Physicals and periodic random drug testing?
YesNo

j) A transitional duty/light duty program for injured workers?
YesNo

k) Designated employee to coordinate claim activities?
YesNo

l) Working w/ injured worker and insurer's physician panel?
YesNo

Notice: Knowingly presenting false or misleading information in an application for insurance may be a crime and violation of law subjecting
the applicant to criminal and civil penalties.
Arkansas, Louisiana, Rhode Island & West Virginia 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.
Alabama applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who 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.
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 policy holder or claimant
for the purpose of defrauding or attempting to defraud the policy holder 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.
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.
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 of the third degree.
Hawaii applicants: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
Kentucky applicants: 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.
Maine 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 may include imprisonment, fines or a denial of insurance benefits.
Maryland applicants: 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 applicants: 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 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 civil fines and criminal penalties.
New York applicants: 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 material fact thereto commits a
fraudulent insurance act, which is a crime, and shall be also subject to a civil penalty not to exceed five thousand dollars and the stated value of the
claim for each such violation.
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.
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.
Oregon applicants: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application or; (2)
filing a claim containing a false statement as to any material fact maybe violating state law.
Pennsylvania 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 subjects such person to criminal and civil penalties.
Tennessee ,Virginia & 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.
Arbitration statement
Applicable to Utah applicants if the policy will contain an arbitration clause:
Any matter in dispute between you and the company may be subject to arbitration as an alternative to court action pursuant to the rules of (the American
Arbitration Association or other recognized arbitrator), a copy of which is available on request from the company. Any decision reached by arbitration
shall be binding upon both you and the company. The arbitration award may include attorney's fees if allowed by state law and may be entered as a
judgement in any court of proper jurisdiction.

Signature Section

Principal, Owner or Officer Signature

Title

Date