Due to the Coronavirus, our office will be operating remotely in order to keep our staff free from infection. For latest update on the virus as it pertains to Florida please access our link. Office: 813.995.6013 Ext: 101 / Direct: 727.755.3060 Email: info@centurioninsuranceafs.com

Workers Compensation Section






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

    State 1








    State 2








    State 3




















    Please list your 8 largest clients based on revenue:

    A




    B




    C




    D




    Employee pay scale (Hourly)

    a. Supervisors(Hourly)




    b. Unarmed Guards(Hourly)




    c. Armed Guards





    YesNo
    If yes, please explain below:



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


    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


    New York CityChicagoWashington DCBostonSan FranciscoLos Angeles


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    Signature Section