State *
AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
What Trade Associations are you a member of? *
Background Checks on employees?
Do you have/follow a written job safety program? *
Do Employees respond to site of alarm? *
Do you provide workers compensation coverage for all your employees? *
List states in which you do business *
If NY, any operation within the 5 buroughs?
Describe Employee Training and Certification *
Security/Fire Alarm Installation *
Security/Fire Alarm Maintenance *
Security Patrol Services (unarmed guards only) *
CCTV/Access/AV/Smart Home Installation/Repair *
Hood Vent/Systems Installation/Repair *
Low Voltage Wiring: Cable TV, Fiber Optic, Broadband, etc. *
Describe all Activities in Detail *
Do you install, repair, or perform maintenance on fire sprinkler or suppression systems? *
If yes, what percentage of your operations? Please note coverage for sprinkler work may not be available.
Apartments & Homes (2 stories or less) *
Apartments & Homes (3 stories or more) *
Apartments - High Rise Apartments (7 stories or more) *
Commercial Businesses (Auto Dealers, Retail Stores, Restaurants) *
Medical Facilities/Nursing Homes *
Penal Facilities/Prisons *
Transportation (Airports, Train Stations, etc.) *
Vehicles (Buses, Law Enforcement. etc.) *
Previous Year Gross Sales *
Upcoming Year Gross Sales *
Annual Subcontract Cost * Program requires insureds to utilize acceptable written contracts with customers of subcontractor
Do you require your subcontractors to carry a minimum of $1 million/$2 million aggregate Limits? *
Do your subcontractors sign a written contract that has an indemnity agreement holding you harmless and name you as additional insured on their insurance? *
Do you obtain certificates of insurance from your subcontractors? *
Percent of customers with signed contracts containing quality protective clauses *
Do your contracts include a limitation of liability/liquidated damages clause? *
What is the dollar amount of your standard limitation? *
Have you had any claims in the past 3 years? *
Do you want Employee Benefits Liability Coverage? *
Please check any of the following *
Hired/Non-Owned Insurance Quote? * (Supplemental Application required).
Number of vehicles up to 10,000 lbs.
Number of vehicles over 10,000 lbs.
Auto Liability Carrier Name
Workers’ Compensation Carrier Name
1. Copy of all subcontract agreements * If more than one file, please use a ZIP folder to upload.
2. Certificates of insurance from all subcontractors * If more than one file, please use a ZIP folder to upload.
3. Sample copies of all customer agreements * If more than one file, please use a ZIP folder to upload.
4. Currently Valued Loss runs from your prior carrier for the past 3 years or signed known loss letter * If more than one file, please use a ZIP folder to upload.
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