Alarm Installation & Monitoring Insurance Questionnaire

Alarm Installation & Monitoring Insurance Questionnaire
Applicant's Name: *
Address: *
Mailing Address
Address (cont): *
Mailing Address - continued
Contact: *
Email *
Telephone: *
Website
Fax:
Applicant is:

Individual Partnership Corporation Other (specify) Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
GENERAL INFORMATION
Please provide customer contract. If installation and monitoring, provide two separate contracts.
1. Date you need coverage:
2. In what state(s) do you conduct business?
3. How many years have you been in business?
4. Are you a member of any trade organizations?

Yes No
4a. If yes, please list

5. What percentage of your work is:

Commercial

Residential

Percentage

6. Please indicate number of employees:

Full-Time

Part-Time

Number

Note: Employees' include: Sole proprietors, Partners, Executive Officers, Seasonal employees, Part-time employees, Full-time employees.
7. What pre-employment screening is used? Please explain:
8. Have you had any losses in the last 5 years? (Please provide loss runs for last 5 years.)

Yes No