Liability Insurance Application for: Security Guard Services Private Investigation Agencies Lie Detection Agencies Alarm Companies

Size: px
Start display at page:

Download "Liability Insurance Application for: Security Guard Services Private Investigation Agencies Lie Detection Agencies Alarm Companies"

Transcription

1 Executive Risk Indemnity Inc. Home Office Wilmington, Delaware BROWNYARD PROGRAMS, LTD. One Wingam Drive P.O. Box 169 Islip, NY Phone (516) Toll Free (800) Fax (516) Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut Liability Insurance Application for: Security Guard Services Private Investigation Agencies Lie Detection Agencies Alarm Companies I. GENERAL INFORMATION 1. Name: Date: 2. Physical Address: City: State: ZIP: Please list additional locations on a separate page. 3. Mailing Address (if different from above): City: State: ZIP: 4. Contact: Title: Telephone: ( ) Fax Number: ( ) [ ] Corporation [ ] Partnership [ ] Individual [ ] Other: 5. Date established: License number(s): State(s) of Issuance: 6. Do you operate in other states? As an attachment, please provide a list with the percentage of operations in each state. 7. Effective Date desired: 8. a) General Liability Limits desired: $1,000,000 $5,000,000 $10,000,000 Other: b) Other coverages desired: Umbrella Liability (separate application required) Employment Practices Liability (separate application required) Workers Compensation (separate application required) Fidelity Bond (separate application required) 9. Type of business activity (please check all applicable): Security Guard/Patrol (complete Section II) Armored Car/Courier (complete Section II) Executive Protection (complete Section II) Burglar/Fire Alarm (complete Section III) Private Investigation (complete Section IV) Janitorial (separate application required) Temp Help (separate application required) Other: 1

2 10. a) Prior insurance information: Please attach current loss runs for the past five (5) years. (Please provide insurance company, limits, and premium information for the past five (5) years even if you have had no losses.) INSURANCE CO. POLICY PERIOD LIABILITY LIMITS PREMIUM TOTAL # OF CLAIMS b) Do you have any knowledge concerning any incidents that have occurred prior to the date of this Application and which may result in a future claim? Please provide details: c) Please explain, in detail, any losses over ten thousand dollars ($10,000): (Please attach separate pages if needed.) 11. Please provide the names of your ten (10) largest clients: II. GUARDS 1. What background do the principals of this company have in the guard industry? 2. Please provide the names of all clients to whom you assign armed guards: 3. Please list all security association memberships: 2

3 4. Do guards perform any other duties which would not be considered typical guard duties, such as monitoring temperatures? If Yes, please describe: 5. Guard Training (Please provide the number of hours of training for each category): Total number of annual training hours On-the-job training Classroom training with films Classroom training with instructor Firing range Other - Describe: 6. Guard Screening Fingerprints Drug Testing Honesty Testing Psychological Testing Prior Employer Personal Interview 7. Guard Supervision Please describe supervisor s duties: Do supervisors perform guard duties? Are the supervisor s hours billed to the clients? 8. Canine Patrol Total Number of Guard Dogs: With Handlers: Without: Please describe training of the dogs: 9. Average hourly guard billing rate: $ Average hourly guard pay rate: $ Average hourly supervisor pay rate: $ 10. Total number of annual guard hours billed: 3

4 11. PLEASE ATTACH MOST RECENT FINANCIAL STATEMENT, IF AVAILABLE. CLASSIFICATION TOTAL # OF EMPLOYEES ARMED FULL-TIME PART-TIME ANNUAL PAYROLL Executive/Clerical/Sales $ Supervisors $ Security Guards $ TOTAL $ $ ANNUAL SALES 12. Description of Operations: (Please provide approximate percentage (%) in each category.) CATEGORY UNARMED ARMED CATEGORY UNARMED ARMED Airports % % Hotels/Motels/Inns/Resorts % % Apartments/Condos/Co-Ops % % Industrial (Factories, % % Warehouses, etc.) Armored Cars % % Low Income Housing % % Banks/Office Buildings % % Movies/Theaters % % Bars/Discos/Clubs % % Museums/Galleries % % Bus/Train Terminals % % Parking Garages % % Colleges/Universities % % Patrol Cars % % Concerts (Rap, Rock, etc.) % % Restaurants % % Construction Sites % % Retail (Stores/Markets) % % Conventions/Trade Shows % % Security Consultation % % Courier Escort % % Shopping Malls % % Executive Protection % % Social Services/Clinics % % Fast Food Establishments % % Special Events (describe): % % Gated Communities % % Sporting Events % % Golf/Tennis/Yacht Clubs % % Strike Duty % % Governmental Contracts % % Trucking Terminals % % High Schools % % Waterfront/Piers/Marinas % % Hospitals/Institutions % % Other (describe): % % III. ALARMS 1. What background do the principals of this company have in the alarm business? 4

5 2. a) PLEASE ATTACH MOST RECENT FINANCIAL STATEMENT, IF AVAILABLE. CLASSIFICATIONS TOTAL # OF EMPLOYEES ARMED FULL-TIME PART-TIME ANNUAL PAYROLL Executive/Clerical $ Sales/Distribution $ $ Installation & Service $ $ Monitoring $ $ Guard Response $ $ Other (describe): $ $ TOTAL $ $ ANNUAL RECEIPTS b) Alarms are: Fire Only: % Burglary Only: % Gas Detection: % Medical Alert: % Combination (Fire, Burglary, etc.): % Temperature Control: % Other: % Please explain: c) Installations are: Central Station: % Local: % d) Clients are: Commercial: % Residential: % e) Total number of Central Station subscribers: Number under contract: f) Does the company sell anything under its own label? If Yes, please explain: g) Is the company engaged in any manufacturing? If Yes, please explain: h) Does the company use products approved by Factory Mutual or Underwriters Laboratories? If Yes, please explain: 3. a) Does the company monitor its own systems? If No, who monitors? b) Is the monitor a telephone answering service? c) Does the company own and operate this telephone answering service? d) Does a contract exist between applicant and monitoring company? e) Does the company require certificates of insurance from the monitoring company? 5

6 4. Has the company sold its recurring revenue to another company? If Yes, is this revenue reported on this Application? 5. Does the company subcontract work to others? If Yes, what type of work? Are certificates of insurance obtained from subcontractors? 6. Does the company have a training program? If Yes, please describe: 7. Are employees licensed or certified? 8. Does the company s contract include a liquidated damage clause? Are there any contracts without this clause? 9. Please attach a copy of each of the company s contract forms along with any invoice or bill of sale. Be sure to include all contract forms, including old forms still in effect. 10. Please explain alarm response procedures: 11. Please list all alarm association memberships: IV. INVESTIGATIONS 1. a) What background do the principals of this company have in the private investigation and/or lie detection business? b) Will the principals conduct investigations/lie detection? 2. Please describe the background, experience and educational requirements for investigators: 3. Please describe the background, experience and educational requirements for Polygraph/Lie Detection Examiners: 4. Does the company utilize a standard contract with its investigation and/or lie detection clients? If Yes, please provide us with a copy of the standard contract. 6

7 5. Please list all investigative and polygraph association memberships: 6. PLEASE ATTACH MOST RECENT FINANCIAL STATEMENT, IF AVAILABLE. CLASSIFICATION TOTAL # OF EMPLOYEES ARMED FULL-TIME PART-TIME ANNUAL PAYROLL Executive/Clerical/ Sales $ Supervisors $ Investigators $ Polygraph/Lie Detection $ Examiners Independent Contractors $ TOTAL $ $ ANNUAL RECEIPTS 7. Description of Operations: (Please provide approximate percentage (%) in each category.) CATEGORY UNARMED ARMED CATEGORY UNARMED ARMED Arson % % Matrimonial/Domestic % % Child Custody % % Paper/Pencil Honesty Testing % % Corporate % % Polygraph % % Credit % % Pre-Employment % % Criminal % % Process Server % % Drug Testing % % PSE % % Electronic Surveillance % % Repossessions % % (describe): Forensic Accounting % % Shopping Service % % Genealogical % % Skip Tracing % % Insurance % % Undercover % % Kidnap and Ransom % % Other (describe): % % NOTICE TO APPLICANT PLEASE READ CAREFULLY. FOR THE PURPOSES OF THIS APPLICATION, THE UNDERSIGNED AUTHORIZED AGENT OF THE PERSON(S) AND ENTITY(IES) PROPOSED FOR THIS INSURANCE DECLARES THAT TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS IN THIS APPLICATION, AND IN ANY ATTACHMENTS, ARE TRUE AND COMPLETE. THE UNDERWRITER IS AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION. ACCEPTING THIS APPLICATION DOES NOT BIND THE UNDERWRITER TO COMPLETE, OR THE APPLICANT TO PURCHASE, THE INSURANCE. THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE UNDERWRITER AND ALONG WITH THE APPLICATION IS CONSIDERED PHYSICALLY ATTACHED TO THE POLICY AND WILL BECOME A PART OF IT. THE UNDERWRITER WILL HAVE RELIED UPON THIS APPLICATION AND ATTACHMENTS IN ISSUING ANY POLICY. THE APPLICATION WILL BECOME A PART OF SUCH POLICY IF ISSUED. IF THE INFORMATION IN THIS APPLICATION OR IN ANY ATTACHMENT MATERIALLY CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE POLICY EFFECTIVE DATE, THE APPLICANT WILL NOTIFY THE UNDERWRITER, WHO MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION OR AGREEMENT TO BIND INSURANCE. 7

8 NOTICE TO ARKANSAS, MINNESOTA, AND OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE 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, WHICH IS A CRIME. 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 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. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE, INSURANCE COMPANY, OR SELF-INSURED PROGRAM, FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY 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 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. NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD. 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 OKLAHOMA APPLICANTS: 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 AND TEXAS APPLICANTS: ANY PERSON WHO MAKES AN INTENTIONAL MISSTATEMENT THAT IS MATERIAL TO THE RISK MAY BE FOUND GUILTY OF INSURANCE FRAUD BY A COURT OF LAW. NOTICE TO 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. NOTICE TO VIRGINIA 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. 8

9 APPLICANT: BY (President, Chairman, or CEO): TITLE: DATE: 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. REQUIRED INFORMATION PRODUCED BY (Insurance Agent or Broker): Please print and sign name FIRM NAME: TAXPAYER ID OR SOCIAL SECURITY NO.: PRODUCER LICENSE NO.: ADDRESS (No., Street, City, State, and ZIP): ADDRESS: SUBMITTED BY (Firm): ADDRESS (No., Street, City, State, and ZIP): TAXPAYER ID OR SOCIAL SECURITY NO.: PRODUCER LICENSE NO.: 9

RENEWAL APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE

RENEWAL APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE Executive Risk Indemnity Home Office Wilmington, Delaware 19808 Administrative Offices/Mailing 82 Hopmeadow Simsbury, Connecticut RENEWAL APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE NOTICE:

More information

SAFETY NET SHORT FORM INTERNET LIABILITY INSURANCE APPLICATION

SAFETY NET SHORT FORM INTERNET LIABILITY INSURANCE APPLICATION Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey 07059 Executive Risk Indemnity Inc. 2711 Centerville Road Suite 400, Wilmington, Delaware 19808 SAFETY NET SHORT FORM INTERNET

More information

APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE

APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE Monroe Insurance Brokerage, Inc. Home Office M o n t e r e y, C a l i f o r n i a 9 3 9 4 0 APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH THIS APPLICATION

More information

General Liability Insurance Application for Security Guard and Detective/Private Investigators

General Liability Insurance Application for Security Guard and Detective/Private Investigators www.aauins.com General Liability Insurance Application for Security Guard and Detective/Private Investigators General Information 1. Name 2. Physical address 3. Mailing address 4. Effective date requested

More information

BY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY )

BY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY ) BY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY ) NOTICE: PLEASE ANSWER ALL OF THE FOLLOWING INQUIRIES.

More information

APPLICATION FOR DIRECTORS AND OFFICERS LIABILITY INSURANCE POLICY INCLUDING EMPLOYMENT PRACTICES LIABILITY COVERAGE

APPLICATION FOR DIRECTORS AND OFFICERS LIABILITY INSURANCE POLICY INCLUDING EMPLOYMENT PRACTICES LIABILITY COVERAGE APPLICATION FOR DIRECTORS AND OFFICERS LIABILITY INSURANCE POLICY INCLUDING EMPLOYMENT PRACTICES LIABILITY COVERAGE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES, SUBJECT TO ITS TERMS, ONLY

More information

Alarm or Security System Design, Installation, Service or Repair Application

Alarm or Security System Design, Installation, Service or Repair Application Alarm or Security System Design, Installation, Service or Repair Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent Applicant

More information

Alarm or Security System Design, Monitoring, Installation, Service or Repair Application

Alarm or Security System Design, Monitoring, Installation, Service or Repair Application Alarm or Security System Design, Monitoring, Installation, Service or Repair Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name

More information

Commercial Insurance Applying - A Technical Analysis

Commercial Insurance Applying - A Technical Analysis Investigator Liability Insurance Application Application Requirements: FULLY COMPLETED APPLICATION: If additional space is needed, please use your firm's letterhead. Application must be Dated and Signed

More information

APPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE

APPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE Executive Risk Management Associates 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED

More information

BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK SPECIALTY INSURANCE COMPANY (THE UNDERWRITER )

BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK SPECIALTY INSURANCE COMPANY (THE UNDERWRITER ) BY COMPLETING THIS YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK SPECIALTY INSURANCE COMPANY (THE UNDERWRITER ) NOTICE: THE LIMIT OF LIABILITY TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED AND MAY

More information

APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE

APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE Executive Risk Indemnity Inc. Home Office Wilmington, Delaware 19805-1297 Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR ACCOUNTANTS PROFESSIONAL

More information

Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group)

Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group) Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group) NETWORK SECURITY AND PRIVACY LIABILITY RENEWAL APPLICATION PORTIONS

More information

1. Name of Applicant: (Whenever used in this Application, the term Applicant shall mean the Parent Corporation and all subsidiaries.

1. Name of Applicant: (Whenever used in this Application, the term Applicant shall mean the Parent Corporation and all subsidiaries. Executive Risk Indemnity Inc. Home Office Wilmington, Delaware 19805-1297 Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR MANAGED CARE SPECIFIC

More information

Executive Protection Portfolio SM Fiduciary Liability Coverage Application

Executive Protection Portfolio SM Fiduciary Liability Coverage Application BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK INDEMNITY INC. (THE COMPANY ) NOTICE: THE FIDUCIARY LIABILITY COVERAGE SECTION OF THIS POLICY PROVIDES CLAIMS MADE COVERAGE,

More information

Kidnap Ransom & Extortion Coverage Iraq and Pakistan Supplemental Application

Kidnap Ransom & Extortion Coverage Iraq and Pakistan Supplemental Application BY COMPLETING THIS KIDNAP RANSOM & EXTORTION COVERAGE (KR&E) FOR IRAQ AND PAKISTAN SUPPLEMENTAL APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE:

More information

PENSION AND WELFARE FUND FIDUCIARY DISHONESTY POLICY APPLICATION

PENSION AND WELFARE FUND FIDUCIARY DISHONESTY POLICY APPLICATION BY COMPLETING THIS THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE: READ THE ENTIRE CAREFULLY BEFORE SIGNING. INSTRUCTIONS: 1. Whenever used in this Pension

More information

Crime Social Engineering Fraud Supplemental Application

Crime Social Engineering Fraud Supplemental Application BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE: THE COVERAGE AFFORDED UNDER THIS COVERAGE SECTION DIFFERS IN SOME RESPECTS FROM THAT AFFORDED

More information

NON PROFIT MANAGEMENT LIABILITY APPLICATION

NON PROFIT MANAGEMENT LIABILITY APPLICATION NON PROFIT MANAGEMENT LIABILITY APPLICATION THIS APPLICATION IS FOR A CLAIMS MADE POLICY. "CLAIMS" MUST BE FIRST MADE AGAINST AN "INSURED PERSON" DURING THE "POLICY PERIOD" OR ANY APPLICABLE EXTENDED REPORTING

More information

Security Guards and Related Operations General Liability Application

Security Guards and Related Operations General Liability Application Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm.

More information

Agent ALARM OR SECURITY SYSTEM DESIGN, INTALLATION, SERVICE OR REPAIR

Agent ALARM OR SECURITY SYSTEM DESIGN, INTALLATION, SERVICE OR REPAIR Agency Name: Address: Contact Name: Phone: Fax: Email: Alarm or Security System Design, Installation, Service, Repair Or Monitoring Application TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION

More information

Application for Fire & Water Restoration Contractors

Application for Fire & Water Restoration Contractors Application for Fire & Water Restoration Contractors Please complete the application in its entirety. Instructions Note: Completion of this application does not bind coverage. The applicant s acceptance

More information

Executive Risk Indemnity Inc.

Executive Risk Indemnity Inc. Executive Risk Indemnity Inc. Home Office: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR MANAGEMENT LIABILITY INSURANCE FOR PROFESSIONAL FIRMS NOTICE: THE POLICY FOR WHICH APPLICATION

More information

DIRECTORS AND OFFICERS LIABILITY-NOT FOR PROFIT ORGANIZATION APPLICATION

DIRECTORS AND OFFICERS LIABILITY-NOT FOR PROFIT ORGANIZATION APPLICATION DIRECTORS AND OFFICERS LIABILITY-NOT FOR PROFIT ORGANIZATION APPLICATION RSUI Indemnity Company Landmark American Insurance Company NOTICE: THIS IS A CLAIMS MADE AND REPORTED POLICY THAT APPLIES ONLY TO

More information

MULTIMEDIA SM LIABILITY Application for Advertising Agencies

MULTIMEDIA SM LIABILITY Application for Advertising Agencies BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH EXECUTIVE RISK INDEMNITY INC. ( Insurer ) NOTICE: THE LIMIT OF LIABILITY TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED AND MAY

More information

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group)

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) EMPLOYMENT PRACTICES LIABLITY INSURANCE APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION

More information

AVIATION GENERAL LIABILITY INSURANCE APPLICATION

AVIATION GENERAL LIABILITY INSURANCE APPLICATION AVIATION GENERAL LIABILITY INSURANCE APPLICATION Applicant s Name: Mailing Address: Name of Airport: Applicant is Individual Partnership Joint Venture Corporation Other: Type of Business is: FBO FAA Certified

More information

BY COMPLETING THIS NEW BUSINESS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY )

BY COMPLETING THIS NEW BUSINESS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) .. BY COMPLETING THIS THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE: INSURING CLAUSE A OF THE POLICY PROVIDES CLAIMS MADE COVERAGE, WHICH APPLIES ONLY TO "CLAIMS"

More information

Alarm Installation, Servicing, Monitoring or Repair General Liability Application

Alarm Installation, Servicing, Monitoring or Repair General Liability Application Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Surplus Lines Insurance

More information

Credit Insurance Application

Credit Insurance Application Credit Insurance Application 1. General Information Name of Applicant Address City State Zip Phone Fax Email Representative and title of person designated to receive all notices concerning this insurance:

More information

Malpractice Insurance For International Board Certified Lactation Consultants

Malpractice Insurance For International Board Certified Lactation Consultants Malpractice Insurance For International Board Certified Lactation Consultants 1) Please print a copy of this application to your desktop printer. 2) Complete this hard copy by hand, answering all questions

More information

Travel Agents & Tour Operators Professional Liability Insurance Application

Travel Agents & Tour Operators Professional Liability Insurance Application Travel Agents & Tour Operators Professional Liability Insurance Application For more information, contact: 1.800.803.1213 fax 516.294.1821 info@berkely.com www.berkely.com Aon Affinity is the brand name

More information

Alarm Installation, Servicing, Monitoring or Repair General Liability Application

Alarm Installation, Servicing, Monitoring or Repair General Liability Application Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide

More information

ERRORS & OMISSIONS RENEWAL APPLICATION

ERRORS & OMISSIONS RENEWAL APPLICATION ERRORS & OMISSIONS RENEWAL APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE

More information

OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application

OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application NOTICE: This is an application for a claims-made and reported policy. Subject to its terms, this policy

More information

ERRORS & OMISSIONS INSURANCE APPLICATION

ERRORS & OMISSIONS INSURANCE APPLICATION ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: Indian Harbor Insurance Company 505 Eagleview Blvd. Suite 100 Dept: Regulatory Exton, PA 19341-1120 Telephone: 800-688-1840 THIS IS AN APPLICATION

More information

MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION

MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION NOTICE: THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY, WHICH, SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO CLAIMS WHICH ARE BOTH FIRST MADE

More information

Application For Business and Management (BAM) Indemnity Insurance

Application For Business and Management (BAM) Indemnity Insurance Application For Business and Management (BAM) Indemnity Insurance NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE, SUBJECT TO ITS TERMS, APPLIES ONLY TO ANY CLAIM OR LOSS DISCOVERED (AS APPLICABLE IN

More information

6. Does Applicant encrypt all sensitive and Personally Identifiable Information? Yes No If yes, give details:

6. Does Applicant encrypt all sensitive and Personally Identifiable Information? Yes No If yes, give details: Name of Insurance Company to which Application is made (herein called the Insurer ) CORPORATE IDENTITY PROTECTION NOTICE: AMOUNTS INCURRED FOR DEFENSE COSTS, ADMINISTRATIVE EXPENSES, NOTIFICATION COSTS,

More information

HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION

HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION Please note: This application is intended to be used for HVAC contractors with under $1,000,000 in receipts. On accounts

More information

APPLICATION FOR INSURANCE AGENTS AND BROKERS ERRORS & OMISSIONS LIABILITY INSURANCE

APPLICATION FOR INSURANCE AGENTS AND BROKERS ERRORS & OMISSIONS LIABILITY INSURANCE APPLICATION FOR INSURANCE AGENTS AND BROKERS ERRORS & OMISSIONS LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE APPLIES, SUBJECT TO ITS TERMS, ONLY TO CLAIMS FIRST MADE DURING

More information

(to be shown on policy declarations page) City State Zip

(to be shown on policy declarations page) City State Zip Clubs/Groups & Special Event Insurance Request for Quote Instructions to obtain a Quote: 1. Complete form entirely to receive a quote. If the form is not completed, additional information will have to

More information

Application For Business and Management (BAM) Indemnity Insurance Non-Profit Organizations

Application For Business and Management (BAM) Indemnity Insurance Non-Profit Organizations Northwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com

More information

7 TOW TRUCK PROGRAM SUPPLEMENTAL APPLICATION

7 TOW TRUCK PROGRAM SUPPLEMENTAL APPLICATION LICATION Named Insured: Owner s Name: Web site Address: Address: Type of business Individual Corporation LLC Other Federal Tax ID: I. ELIGIBILITY 1. Are at least 50% of the operations derived towing? Yes

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY GENERAL LIABILITY SUPPLEMENTAL APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE

More information

1. a) Name of Applicant: (Whenever used in this Application, the term "Applicant" shall mean the Parent Corporation and all Subsidiaries.

1. a) Name of Applicant: (Whenever used in this Application, the term Applicant shall mean the Parent Corporation and all Subsidiaries. Executive Risk Indemnity Inc. Home Office Wilmington, Delaware 19805-1297 Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR DIVERSIFIED HEALTHCARE

More information

NAVIGATORS INSURANCE COMPANY Real Estate Professional Errors and Omissions Insurance EXPRESS APPLICATION - Missouri

NAVIGATORS INSURANCE COMPANY Real Estate Professional Errors and Omissions Insurance EXPRESS APPLICATION - Missouri NAVIGATORS INSURANCE COMPANY Real Estate Professional Errors and Omissions Insurance EXPRESS APPLICATION - Missouri To be eligible for this express application you must be able to answer "true" to statements

More information

ERRORS & OMISSIONS INSURANCE APPLICATION

ERRORS & OMISSIONS INSURANCE APPLICATION ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE

More information

Employed Lawyers Professional Liability Application

Employed Lawyers Professional Liability Application Employed Lawyers Professional Liability Application THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED INSURANCE. NOTICE: THE LIMIT OF LIABILITY AVAILABE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED

More information

BONDING & INSURANCE SPECIALISTS AGENCY, INC. (BISA)

BONDING & INSURANCE SPECIALISTS AGENCY, INC. (BISA) BONDING & INSURANCE SPECIALISTS AGENCY, INC. (BISA) 9340 S. Harlem Avenue, Bridgeview, IL 60455 800-346-1031 Fax: 708-598-6686 Instructions APPLICATION FOR FIRE AND WATER RESTORATION CONTRACTORS The coverage

More information

6. Number of employees including principals: Full-time Part-time Seasonal Total

6. Number of employees including principals: Full-time Part-time Seasonal Total Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED

More information

Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110

Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE

More information

Chubb Custom Market Recreational Marine Piers, Wharves & Docks Application

Chubb Custom Market Recreational Marine Piers, Wharves & Docks Application BY COMPLETING THIS Piers, Wharves & Docks APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH Chubb Group of Insurance Companies (THE COMPANY ) Piers, Wharves & Docks APPLICATION INSTRUCTIONS: 1. Whenever

More information

MISSOURI - THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR EMPLOYEE THEFT CLIENT PREMISES ONLY

MISSOURI - THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR EMPLOYEE THEFT CLIENT PREMISES ONLY , a stock insurance company, herein called the Insurer MISSOURI - THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR EMPLOYEE THEFT CLIENT PREMISES ONLY AGENCY NAME: HARTFORD

More information

Part 1: APPLICANT INFORMATION

Part 1: APPLICANT INFORMATION AMERICAN ACADEMY OF STATE CERTIFIED APPRAISERS A RISK PURCHASING GROUP REAL ESTATE APPRAISERS PROFESSIONAL LIABILITY APPLICATION NEW BUSINESS NOTE: This is an application for a Claims Made policy. Coverage

More information

Loss/Collision Damage Waiver

Loss/Collision Damage Waiver Loss/Collision Damage Waiver HOW TO FILE A CLAIM 1. Complete all items on the attached claim form. 2. Attach the following documents: Copy of rental car agreement Copy of police report Proof of payment

More information

Application For ACE EXPRESS Non Profit Organization Management Indemnity Package

Application For ACE EXPRESS Non Profit Organization Management Indemnity Package Application For ACE EXPRESS n Profit Organization Management Indemnity Package NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE, SUBJECT TO ITS TERMS, APPLIES ONLY TO ANY CLAIM MADE AGAINST ANY OF THE

More information

APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY GENERAL INFORMATION

APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY GENERAL INFORMATION APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY Instructions for Completing This Application Please read carefully and fully answer all questions and submit all requested information

More information

PART I. TELL US WHO YOU ARE

PART I. TELL US WHO YOU ARE Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group) One Beacon Lane Canton, MA 02021 HEALTH CARE CONSULTANT PROFESSIONAL

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION

EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION THIS IS AN APPLICATION FOR A POLICY THAT IS WRITTEN ON A CLAIMS-MADE BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE

More information

RENEWAL Application for Business and Management (BAM) Indemnity Insurance

RENEWAL Application for Business and Management (BAM) Indemnity Insurance rthwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com

More information

Lexington Insurance Company

Lexington Insurance Company LIQUOR LIABILITY INSURANCE APPLICATION Application Instructions A. Please type or complete the application in ink. B. If additional space is needed, please use your firms letterhead. Instant Indication

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION

EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION NOTICES: THE EMPLOYMENT PRACTICES LIABILITY COVERAGE PART/ENDORSEMENT PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR

More information

Lexington Insurance Company

Lexington Insurance Company BURGLAR & FIRE ALARM, AND TELECOMMUNICATIONS PROPERTY Application Instructions A. Please type or complete the application in ink. B. If additional space is needed, please use your firms letterhead. Instant

More information

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group)

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS

More information

Artisan Contractors Application

Artisan Contractors Application Agency Name: Address: Contact Name: Phone: Fax: Email: Artisan Contractors Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION 610-668-7100 MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY

More information

Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110

Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY NETWORK SECURITY SUPPLEMENTAL APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND

More information

Miscellaneous Professional Liability Application

Miscellaneous Professional Liability Application Name of insurance company to which Application is made (the Insurer ) Miscellaneous Professional Liability Application NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS

More information

RENEWAL Application for Business and Management (BAM) Indemnity Insurance

RENEWAL Application for Business and Management (BAM) Indemnity Insurance rthwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com

More information

Sample Business Administration Letters of Application

Sample Business Administration Letters of Application HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR

More information

Security Guards and Related Operations General Liability Application

Security Guards and Related Operations General Liability Application 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 Fax (480) 483-6752 www.scottsdaleins.com Security Guards and Related Operations General Liability Application Applicant s Name Mailing

More information

NON OWNED & HIRED AUTO

NON OWNED & HIRED AUTO 1. Applicant Information A) Name (First named insured and other named insureds) OWNED AUTO LIABILITY B) Do you own any vehicle (in your company s name)? If yes, who is the insurer of these vehicles? C)

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION

EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION THIS IS AN APPLICATION FOR A POLICY THAT IS WRITTEN ON A CLAIMS-MADE BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE

More information

LIQUOR LIABILITY PRODUCT APPLICATION

LIQUOR LIABILITY PRODUCT APPLICATION LIQUOR LIABILITY PRODUCT APPLICATION ACE Group GENERAL APPLICANT INFORMATION: Applicant s name: Mailing address: City: State: Zip: E-mail address of primary contact: Website address: Phone number: Inspection

More information

BEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION

BEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION BEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION NOTICE: INSURING AGREEMENTS I.A., I.C., I.D. AND I.F. OF THIS POLICY PROVIDE COVERAGE

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability COMMITTED TO A MAKING DIFFERENCE Personal Lines Insurance Agents Professional Liability INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION All questions must be answered and application must

More information

Eidyia Insurance Services

Eidyia Insurance Services Eidyia Insurance Services MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS. NOTICE: THE LIMIT OF LIABILITY AVAILABLE TO

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability Personal Lines Insurance Agents Professional Liability PART I - AGENCY DETAILS P.O. Box 2909 Jacksonville, FL 32203-2909 Phone: 800-342-2498 Fax: 904-355-7611 www.shellyins.com INSURANCE AGENTS AND BROKERS

More information

National Union Fire Insurance Company of Pittsburgh, Pa. LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION

National Union Fire Insurance Company of Pittsburgh, Pa. LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION National Union Fire Insurance Company of Pittsburgh, Pa. (herein called the Insurer ) LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION NOTICE THIS IS AN APPLICATION FOR INSURANCE WRITTEN ON A CLAIMS

More information

GENERAL LIABILITY SUPPLEMENTAL APPLICATION

GENERAL LIABILITY SUPPLEMENTAL APPLICATION AFB MEDIA TECH PROFESSIONAL AND TECHNOLOGY BASED SERVICES, TECHNOLOGY PRODUCTS, COMPUTER NETWORK SECURITY, AND MULTIMEDIA AND ADVERTISING LIABILITY INSURANCE POLICY GENERAL LIABILITY SUPPLEMENTAL APPLICATION

More information

Individual Partnership D/B/A (if applicable): Corporation 2. P.O Box: Phone No.:

Individual Partnership D/B/A (if applicable): Corporation 2. P.O Box: Phone No.: Whenever used in this Application, the term Applicant means the Named Insured and any other entity proposed for coverage. ENDURANCE AGENCY ADVANTAGE APPLICATION THIS IS AN APPLICATION FOR INSURANCE WRITTEN

More information

ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION AUCTIONEERS ERRORS AND OMISSIONS

ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION AUCTIONEERS ERRORS AND OMISSIONS ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION AUCTIONEERS ERRORS AND OMISSIONS 1. Name and Address of Applicant: (Please include DBA s/subsidiaries, etc.) 2. Employee Information: Indicate Numbers:

More information

ACE American Insurance Company

ACE American Insurance Company Named Applicant: Date: ACE American Insurance Company ACE Advantage ACE American Insurance Company National Association of REALTORS Professional Liability Name of insurance company to which Application

More information

TORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477

TORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477 TORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477 APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE TO ALL APPLICANTS:

More information

Deerfield Insurance Company - A Practical Application

Deerfield Insurance Company - A Practical Application Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED

More information

Hudson Insurance Company 100 William Street, New York, NY 10038

Hudson Insurance Company 100 William Street, New York, NY 10038 Hudson Insurance Company 100 William Street, New York, NY 10038 APPLICATION FOR DIRECTORS & OFFICERS INSURANCE POLICY COMPLETION OF THIS APPLICATION DOES NOT COMMIT OR BIND THE UNDERSIGNED TO PURCHASE

More information

Primary Commercial Liability Insurance Application

Primary Commercial Liability Insurance Application Name of Insured:(Attach separate sheet if necessary) Address of Insured: Provide names of any subsidiaries or affiliated company(s) to be covered: 1. 2. 3. List all additional insureds to be named with

More information

Insurance Agents and Brokers Professional Liability

Insurance Agents and Brokers Professional Liability Insurance Agents and Brokers Professional Liability Quaker Special Risk P.O. Box 1350 Eatontown, NJ 07724 Phone: 800 447-4180 Fax: 732 223 9072 INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION

More information

Caterers and Halls General Liability and Miscellaneous Articles Application

Caterers and Halls General Liability and Miscellaneous Articles Application Caterers and Halls General Liability and Miscellaneous Articles Application Applicant s Name: Agency Name: Agent: Mailing Address: Address: Location Address: E-Mail: Phone: Web site Address: PROPOSED EFFECTIVE

More information

APPLICATION FOR EMPLOYEE BENEFIT PLAN FIDUCIARY INSURANCE

APPLICATION FOR EMPLOYEE BENEFIT PLAN FIDUCIARY INSURANCE APPLICATION FOR EMPLOYEE BENEFIT PLAN FIDUCIARY INSURANCE NOTICE: THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THE POLICY FOR WHICH THIS APPLICATION IS MADE IS LIMITED TO LIABILITY FOR

More information

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES ONLY TO CLAIMS FIRST MADE DURING THE POLICY PERIOD AND REPORTED TO THE COMPANY DURING THE

More information

THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY

THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY FLEXI PLUS FIVE APPLICATION NOT-FOR-PROFIT ORGANIZATION DIRECTORS AND OFFICERS LIABILITY INSURANCE EMPLOYMENT PRACTICES LIABILITY INSURANCE FIDUCIARY LIABILITY INSURANCE WORKPLACE VIOLENCE COVERAGE INTERNET

More information

1. Insured Name: 2. Insured Address: 3. Insured Contact: Phone: A B C Location

1. Insured Name: 2. Insured Address: 3. Insured Contact: Phone: A B C Location Chubb Group of Insurance Companies 202 Hall s Mill Road, Whitehouse Station, NJ 08889 SOLAR ENERGY APPLICATION SUPPLEMENT APPLICANT INFORMATION 1. Insured Name: 2. Insured Address: 3. Insured Contact:

More information

SmartPro Property Managers E&O Application

SmartPro Property Managers E&O Application NOTICE: THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED COVERAGE, WHICH APPLIES ONLY TO "CLAIMS" FIRST MADE AND REPORTED IN WRITING DURING THE "POLICY PERIOD," OR ANY EXTENDED REPORTING PERIOD. THE LIMIT

More information

QUESTIONNAIRE PRIVATE INVESTIGATOR / SECURITY GUARD

QUESTIONNAIRE PRIVATE INVESTIGATOR / SECURITY GUARD QUESTIONNAIRE PRIVATE INVESTIGATOR / SECURITY GUARD Please answer all questions fully. Submit this Questionnaire with a completed ACORD Commercial Insurance Applicant Information Section and prior carrier

More information

How to Apply For a Liquor Job

How to Apply For a Liquor Job LIQUOR LIABILITY INSURANCE APPLICATION Application Instructions A. Please type or complete the application in ink. B. If additional space is needed, please use your firm s letterhead. Instant Indication

More information

LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION

LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY. SUBJECT TO ITS TERMS, THE POLICY APPLIES

More information

Railroad Protective Liability Coverage (Attach/Submit ACORD 801)

Railroad Protective Liability Coverage (Attach/Submit ACORD 801) 1. Applicant Information: A. Name Insured Railroad: Railroad Protective Liability Coverage (Attach/Submit ACORD 801) 1. DBA: 2. Address: 3. City: State: Zip Code: B. Name Designated Contractor: 1. DBA:

More information