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

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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

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