A.	How long has applicant been in business?

B.	Branch offices and locations: 1. 2. 3.

C.	Operations conducted in the following states: State:    Licensed with state? Yes No    License #: State:    Licensed with state? Yes No    License #: State:    Licensed with state? Yes No    License #:

D.	Risk contact, title, phone number:

E.	Total number of employees:

F.	# of unarmed employees   Estimated payroll $   Gross sales $ # of armed employees         Estimated payroll $   Gross sales $ Any armed guards in retail stores? Yes No        Arrest authority? Yes No

G.	Total number of hours billed to clients annually:

H.	Are ALL armed personnel certified for use of firearms by a state agency or a firearms certification school?   Yes No

I.	Does applicant have Workers' Compensation coverage in force?   Yes No

J.	Does applicant lease employees?   Yes No

K.	Does applicant subcontract work?   Yes No If yes, what type?   Are certificates of insurance required from all subcontractors?   Yes No Annual cost of subcontracted work:   $

L.	Are background investigations and checks conducted on new employees?   Yes No If yes, describe procedures used for pre-employment checks:

M.	Does the applicant have a training program for employees?   Yes No If yes, describe: Does applicant have a training manual?   Yes No

N.	Does applicant use a record keeping log for each job?   Yes No

O.	Does applicant use dogs?   Yes No If yes, number with handlers:         without handlers:

P.	List the applicant's ten largest clients. Indicate type of operation performed and duties involved:  1.  2.  3.  4.  5.  6.  7.  8.  9. 10.

Q.	Number of supervisors:         Describe duties below: Do they perform investigative or guard duties?   Yes No Does the applicant bill hours to the client?   Yes No

R.	Is applicant involved in any other operations or business?   Yes No If yes, describe:

S.	Does applicant conduct any operations involving nuclear power plants?   Yes No

T.	Provide ANNUAL PAYROLL by listed operation (include subcontractor payroll not covered by other insurance):
Guard Services Armed Payroll Unarmed Payroll Airport security $ $ Alarm Monitoring: Burglary/fire   $   $ Medical emergency $ $ Alarm response $ $ Baggage handling security $ $ Banks $ $ Construction sites $ $ Criminal detention centers $ $ Fast food restaurants $ $ Housing: Apartments--Public Housing authorities, Section 8, HUD   $   $ Apartments--middle to high income $ $ Condominiums $ $ Homeowners associations $ $ Private residences $ $ Immigration detention centers $ $ Manufacturing/warehousing $ $ Motels/hotels $ $ Offices, hospitals, churches $ $ Parking lot security $ $ Restaurants, night clubs, discos, bars $ $ Bouncers $ $ Retail operations: Clothing   $   $ Department Stores $ $ Liquor stores $ $ Shopping centers $ $ Supermarket/convenience stores $ $ All other $ $ Schools $ $ Special events: Athletic events--describe type:   $   $ Concerts--describe: Rock & Roll   Hard Rock   Rap   Country   Other $ $ Other--describe: $ $ Strike work $ $ Utility property security $ $ Other--describe: $ $
Provide ANNUAL PAYROLL by listed operation (include subcontractor payroll not covered by other insurance):
Private Investigation Armed Payroll Unarmed Payroll Arson investigation $ $ Computer fraud $ $ Corporate--employee dishonesty $ $ Credit pre-employment screening $ $ Domestic $ $ Insurance claim investigation $ $ Legal $ $ Missing Person $ $ Records check $ $ Surveillance--describe: $ $ Undercover operations $ $ Other--describe: $ $
Provide ANNUAL PAYROLL by listed operation (include subcontractor payroll not covered by other insurance):
Miscellaneous Services Armed Payroll Unarmed Payroll Alarm installation, service or repair $ $ Auto repossession $ $ Bail bond operations $ $ Bounty hunters $ $ Bodyguards $ $ Courier or escort services: Armored car service $ $ Courier--nonnegotiable securities $ $ Courier--negotiable securities $ $ Courier escort $ $ Funeral escort $ $ Dog services: With handler $ $ Without handler $ $ Drug surveillance $ $ Drug testing $ $ Firearms certification school $ $ Insurance adjusters $ $ Polygraph work $ $ Process servers $ $ Repossession/collection work $ $ School crossing guards $ $ Security consulting $ $ Security guard school/training for others $ $ Shopping service $ $ Traffic Control $ $ Other--describe: $ $

U.	During the past three years has any company ever cancelled, declined or refused to renew similar insurance for the applicant? (Not applicable to Missouri applicants.) Yes No If yes, explain:

Previous Insurer
Indicate premium and losses for the past three years. Describe all losses.
Year	Company	Policy #	Premium	Losses Paid	Losses Reserved	Description

Additional Comments:

Please give any additional comments about the coverage you desire: