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)
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

	Percentage	Annual Payroll ($)
2a. Security / Fire Alarm
2b. Closed Circuit TV (CCTV)
2c. Entertainment Systems
2d. Central Vacuum Systems
2e. Computer Components
2f. Vehicle Alarms
2g. Access Controls
2h. Medical Alert
2i. Other (Describe below)
Totals (Percentage must equal 100%)

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2