Security and Alarm- Application - Arrowhead General Insurance Agency, Inc.

General Information

Provide current broker/agent details *

Company and DBA *

Contact *

Address *

City *

State *

Zip *

Phone *

Cell *

Fax

Email *

FEIN

Years in Business *

Policy Expiration *

Website *

Do you have a show room?

Yes
No

State License Number: *

What Trade Associations are you a member of? *

Tell us more about your business

Number of Employees *

Number of Owners *

Background Checks on employees?

Yes
No

Do you have/follow a written job safety program? *

Yes
No

Annual Payroll *

Do Employees respond to site of alarm? *

Yes
No

Do you provide workers compensation coverage for all your employees? *

Yes
No

List states in which you do business *

If NY, any operation within the 5 buroughs?

Yes
No

Describe Employee Training and Certification *

Operations

Indicate the % of Gross sales/receipts by type of operation (total of services should equal to 100%)

Do you install, repair, or perform maintenance on fire sprinkler or suppression systems? *

Yes
No

If yes, what percentage of your operations?

Please note coverage for sprinkler work may not be available.

%

Monitoring

Total of all services should equal to 100%.

Types of Locations Protected
Total of all locations should equal to 100%.

Revenue/Contracts Eligibility

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? *

Yes
No

Do your subcontractors sign a written contract that has an indemnity agreement holding you harmless and name you as additional insured on their insurance? *

Yes
No

Do you obtain certificates of insurance from your subcontractors? *

Yes
No

Do your contracts include a limitation of liability/liquidated damages clause? *

Yes
No

Have you had any claims in the past 3 years? *

Yes
No

If yes, please explain

Coverage & Options

Do you want Employee Benefits Liability Coverage? *

Yes
No

G/L E&O Premium *

Name of Carrier *

Please check any of the following *

Hired/Non-Owned Insurance Quote? *

(Supplemental Application required).

Yes
No

If requesting an Umbrella quote, please provide:

Number of vehicles up to 10,000 lbs.

Number of vehicles over 10,000 lbs.

Auto Liability Carrier Name

Limits

Workers’ Compensation Carrier Name

Limits

File Upload

Please include the following with your application:

1. Copy of all subcontract agreements *

If more than one file, please use a ZIP folder to upload.

File name:

File size:

2. Certificates of insurance from all subcontractors *

If more than one file, please use a ZIP folder to upload.

File name:

File size:

3. Sample copies of all customer agreements *

If more than one file, please use a ZIP folder to upload.

File name:

File size:

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.

File name:

File size:

*

By checking this box, I verify that the statements and answers herein are warranted to be true and are made with the knowledge that the Company will act in reliance upon them. This request is designed to solicit information and is not a policy or policy binder on the part of the Applicant, its agency, or the Insurance Company. Any misrepresentations by the Applicant may result in denial of coverage or the cancellation of any subsequently issued policy or policies.

Security and Alarm Application

General Information

Tell us more about your business

Operations

Monitoring

Revenue/Contracts Eligibility

Coverage & Options

File Upload