General Liability Insurance Application

General Liability Insurance Application For Alarm/Electronic Security Installation & Monitoring

(Submissions email: securitysubs@rlicorp.com)

General Information

1. Name

2. Physical address

3. Mailing address

4. Effective date requested Date current coverage expires

5. Contact Person Telephone #

Email address

6. Date established FEIN #

License # Website:

7. Organization type
Individual Partnership Joint Venture Trust Limited Liability Company
Organization (Other than Partnership, Joint Venture, or Limited Liability Company)

8. Have you ever operated under another name? Yes No

Name of entity

9. Industry experience

10. Please list any non-alarm related operations.

11. Do you subcontract work to others? Yes No

a. What operations are subcontracted?

b. What is the cost of the subcontracted work?

c. Does a contract exist between you and the subcontractor company? Yes No

d. Do you require GL or WC certificates from subcontractors? Yes No

e. Do the subcontractors carry GL limits equal to or greater than the limits requested on this application? Yes No

f. Are you named as an additional insured on all subcontractor policies? Yes No

12. What does your pre-employment screening process include?
Criminal Background Driving Record Drug Screen Fingerprint Check Polygraph Prior Employment Contacted Psychological Test Other

13. Do you have a new employee training program? Yes No

Please describe

Coverage & Limits Section

14. Limits requested
$1M/$2M $1M/$3M $1M/$4M $1M/$5M Other

15. Deductible requested
$0 $1,000 $2,500 $5,000

16. Do you require any of the below coverages to fulfill client contract requirements?
Please note that some of these coverages may require additional premium.
Additional Insured Employee Benefits Liability Hired/Non-owned Auto
Per Project Aggregate Primary Wording Stop Gap Waiver of Subrogation

Do you have a primary commercial auto policy in force? Yes No

17. Do you require excess/umbrella coverage? Yes No

If “Yes,” what limit is needed?
$1M $2M $3M $4M $5M

If excess/umbrella coverage is required please complete the Excess Liability application.

Alarm Operations Section

18. Number of employees Full time Part time

19. Estimated annual revenue Estimated annual payroll

20. Installation % Monitoring %

21. Please provide percentage breakdown for your client base.

22. Please provide percentage breakdown for all alarm installations and monitoring operations below. Some operations may require further explanation.

Please describe:

23. Please describe the type of work being done for New Home Builders i.e. tract homes, condominiums, custom homes.

A “tract home” is defined as a development of five or more individual and freestanding houses which share common or similar design elements, floor plans, blueprints and/or architectural details, and/or which are constructed at the same time, or consecutively, on the same parcel, adjacent parcels, or parcels so located within one geographic area to be considered a single project.

If a portion of the work you are doing for new home builders is for tract homes or condos and another portion is for custom homes, please provide percentages for each (must equal 100%)

Tract homes, condos, townhouses Custom homes

24. Do you take part in operations aboard aircraft, automobiles, mobile equipment and/or boats? Yes No

25. Is monitoring subcontracted or handled by a third party? Yes No

Monitoring Company

26. Do end users sign a monitoring contract? Yes No

Please attach a copy of your standard monitoring contract to this application for review.

27. Does a contract exist between you and the monitoring company? Yes No

Please attach a copy of the contract between you and the monitoring company for review.

28. Do you require certificates of insurance from the monitoring company? Yes No

29. Does the monitoring company name you as an additional insured? Yes No

30. Do you manufacture any products? Yes No

31. Do you employ security officers to provide alarm response? Yes No

If “Yes,” please also submit the Security Guard and Private Investigator Application (SGL 200).

32. Do you perform any work at facilities where explosives are handled or stored or at nuclear power plants? Yes No

Policy Information

33. Please provide prior year policy information below.

34. Have any claims been made over the last five (5) years? Yes No

35. Do you have any knowledge of incidents that could lead to a claim in the future? Yes No

If “Yes,” please explain.

36. Has your insurance been cancelled, declined or non-renewed in the last three (3) years? Yes No

If “Yes,” please explain.

37. Total number of clients.

38. Please list your six (6) largest clients:

Fraud Warnings

Warning – 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 purposes or misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Alabama – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

Arkansas – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado – 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

District of Columbia – WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. [DC Code]

Florida – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Signature Section

Notice to applicants: this application must be completed in full as the quote will be based solely on the information provided. 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. By signing this application, the signor warrants that to their best knowledge all information given is true and accurate.