Fillable Alarm Installation & Monitoring Application*** (All Risks, Ltd)

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Alarm Installation & Monitoring Application*** (All Risks, Ltd)

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  • 14 check-boxes
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National Specialty Programs
Toll-Free: 800-366-5810 • Fax: 410-828-8179
Contact us: programs@ryansg.com
Alarm Installation & Monitoring Application***
*
*
*
L
iquidated damages clause (limit of liability) is required for our program. Before
proceeding with application, please make sure insured’s contract contains this clause.
1. Name ___________________________________________________________________________________________________
(Complete name as it should appear on the policy including Inc., Corp., Ltd., Etc.)
No. Street City County State Zip Code
Audit Contact __________________________________ Phone ( ) ____________________________________
Claims Contact __________________________________ Phone ( ) ____________________________________
€ Corporation
€ Other
er _________________________
______% Alarm Service and Monitoring ______% Consulting
A Burglar & fire alarm installation – residential A $
B Burglar & fire alarm installation – commercial B $
C Burglar & fire alarm monitoring operations C $
D Medical emergency/ Nurse Call systems installation & monitoring D $
E Home detention or penal/correctional/prisons/jail systems installation &
monitoring
E $
F C.C.T.V. installation/ service/ repair F $
G Access control/ card entry systems G $
H Retail sales of equipment H $
I Fire extinguisher servicing/ installation/ testing/ repair I $
J Automatic sprinkler systems servicing/ installation/ testing/ repair J $
K Other – Describe: ____________________________________________________ K $
General Info (Complete For All Lines)
2. Physical Address _________________________________________________________________________________________
ARF 5257 (AL) 010721 Page 1 of 6
RSGprograms.com
3. Mailing Address _________________________________________________________________________________________
No. Street City County State Zip Code
4. Insured's Email Address
5. Inspection Contact __________________________________ Phone ( ) ____________________________________
6. Telephone ( ) ____________________________________ Fax ( ) ______________________________________
9. Policy proposed effective date ____________________ to ____________________
10. Current coverage expires/expired on ____________________
11. Check limit of liability desired: $300,000 $500,000 $1,000,000 € Oth
12. Deductible: $1,000 $2,500 $5,000 Other ________________________________
13. Applicant Classification: ______% Security Service ______% Investigations
14. Estimated annual a. Sales $ ___________
_ b. Payroll $ _____________
15. Operations of applicant (show sales for each – total shown should equal sales in question 14a)
7. Website_______________________________________________FEIN _____________________________________________
8. Date established __________________ License No. ______________________ € Sole Proprietor € Partnership
equipment, boats and yachts? € Yes € No
If yes, please describe __________________________________________________________________________________
________________________________________________________________________________________________________
a. If yes, what is the amount? _____________________________________________________________________________
a. if yes, what is the cost___________________
________________________________________________________________________________________________________
a. If yes, please attach copy of usual performance contract with client
b. If no, whose contract is signed at installation? _________________________________________________________
standard alarm contract with his client? € Yes € No
a. If yes, what is maximum limit allowed? ________________________________________________________________
b. Please attach copy of contract
a. If yes, what is maximum limit allowed? ________________________________________________________________
b. And, what percentage (%) of the contracts have higher liquidated damage limits? ____________________
a. including central station subscribers ________________
b. including central station subscribers under contract ________________
If yes, are response runners armed? € Yes No
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________ Full-Time
________ Part-Time
If yes, please describe __________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
ARF 5257 (AL) 010721 Page 2 of 6
16. Does the insured install/service and/or repair alarms aboard aircrafts, automobiles, mobile
17. Is the monitoring subcontracted out or handled by a third party? € Yes € No
18. Is there any other work subcontracted out? € Yes € No
19. Does the applicant do any manufacturing? € Yes € No
20. Does the applicant sell anything under its own label? € Yes € No
21. If the answer to question 17 and/or 18 is yes, please explain _______________________________________________
22. Are certificates of insurance obtained from ALL subcontractors? € Yes € No
23. Is named insured added as an additional insured on subcontractor’s policy? € Yes € No
24. Does the applicant have his own contract? € Yes € No
25. Does the applicant limit his liability to a stated dollar amount (liquidated damages on his
26. Does the contract offer the option to buy back coverage? € Yes € No
27. Total number of subscribers:
28. Do you respond to your alarms? € Yes € No
29. Will you service a system that you did not install? € Yes € No
30. What specific warranties do you give on an outright sale? ________________________________________________
31. Total number of employees:
________________________________________________________________________________________________________
32. Does the applicant have a training program? € Yes € No
33. Describe screening procedures for prospective employees: ______________________________________________
34. Does the applicant lease employees?
€ Yes € No
RSGprograms.com
Additional Coverages
CHECK ALL THAT APPLY
Additional Insureds _____ Individual _____ Blanket
Waiver of Subrogation _____ Individual _____ Blanket
Primary Wording _____ Individual _____ Blanket
Per Project Aggregate _____ Employee Benefits Liability _____
Stop Gap _____ Hired/Non-owned Auto _____
Current General Liability Information
1. Please provide name of carriers, premiums paid, limits, sales, deductibles, and loss runs for the past 5 years.
YR - _______ YR - _______ YR - _______ YR - _______ YR - _______
Carrier
Premium
Sales
Ded/SIR
Losses
2. Has any company canceled or declined to renew in the past 5 years? € Yes € No
If yes, please explain: ____________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
3. Has the insured ever had a lapse in coverage? € Yes € No
If yes, please explain: ____________________________________________________________________________________
_________________________________________________________________________________________________________
Claim Information
1. Make sure to attach 5 years of currently valued loss runs. (Valued no more than 3 months from date of
application.)
2. Do you require staff to report all unusual incidents and are all incident reports reviewed by
Management? € Yes € No
3. Do you have any knowledge concerning any incidents that have occurred prior to the date
of this application that may give rise to a future claim? € Yes € No
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 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.
________________________________________ ______________________________________ ____________________
Name (type or print) Signature Date
NOTICE TO PRODUCERS
: THE PRODUCER HEREBY WARRANTS THAT THE INFORMATION CONTAINED IN THIS
APPLICATION IS TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE.
____________________________ ____________________________ _______________ __________________________
Name (type or print) Signature Date License #
ARF 5257 (AL) 010721 Page 3 of 6
RSGprograms.com
RSG National Specialty Programs is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a
subsidiary of Ryan Specialty Group, LLC (RSG). RSG National Specialty Programs works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the
public. Some products may only be available in certain states, and some products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC (License
# 0G97516). ©2021 Ryan Specialty Group, LLC
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Optional Coverages
(please attach an ACORD application)
Property
Business Auto
EDP
Umbrella/Excess
C
r
i
m
e
/
E
m
p
l
o
y
e
e Dishonesty
Contractors Equipment
Workers Compensation
Employment Related Practices
U
mbrella/Excess Questionnaire
(
P
l
e
a
s
e
c
o
m
p
l
ete only if desired.)
1. With the exception of leinholders, are any vehicles not solely owned by and registered
to the applicant?
€ Yes
€ No
2. Do over 50% of the employees use their autos in the business?
€ Yes
€ No
3. Is there a vehicle maintenance program in operation?
€ Yes
€ No
4. Are any vehicles leased to others?
€ Yes
€ No
5. Are any vehicles customized, altered or have special equipment?
€ Yes
€ No
6. Do operations involve transporting hazardous material?
€ Yes
€ No
7. Any vehicles used by family members or non employees?
€ Yes
€ No
If so, please identify in remarks.
Remarks:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
10. Does insured have a written personal use policy including: who may and may not drive
are viol
ated?
Yes No
8. Does insured review MVRs at time of hire and annually for all driving employees?
Yes
No
9. Does insured have MVR standards in place, and an action plan if those standards
11. Does insured have a Fleet Safety program in place? Yes No
Yes No
12. Does the applicant have a specific driver recruiting method? € Yes € No
13. Are any drivers not covered by Workers Compensation? € Yes € No
14. Any vehicles owned but not scheduled on this application? € Yes € No
a company owned vehicle, that the company vehicle
(s) may or may not be used for outside
business, and consequences for violation of the policy?
ARF 5257 (AL) 010721 Page 4 of 6
RSGprograms.com
WORKERS’ COMPENSATION
Information Required with Submission
: (Please attach)
1. ACORD Workers’ Compensation application
2. Financials for accounts over $100,000
3. Insurance Carrier Premium and Loss statements which are currently valued (5 years required).
4. Drivers schedule: Names, Dates of Birth & Driver’s License Number required.
5. Experience Mod. Worksheet
6. Risk Identification Number for the NCCI or Appropriate State Rating Bureau or State Fund:
________________________________________________________________________________________
1. Annual employee turnover rate ________%
2. Is the current coverage now in Assigned Risk, State Fund or Voluntary Market? € Yes € No
3. Has any insurance carrier canceled or refused to renew within the past 3 years? € Yes € No
If yes, please explain _________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
4. Do you report all WC claims, regardless of payment having been made on the claim? € Yes € No
If no, please explain: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
5. Employee Benefits Program:
Describe your Employee Benefits Program:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
6. Do you have a transitional duty (light duty) program? € Yes € No
If yes, describe: ______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
7. Who is responsible for safety? ___________________________________________________
8. Do you have a formal safety committee? € Yes € No
If yes, how frequently does it meet and who attends? _________________________________________________________________
_____________________________________________________________________________________________________________________
9. Do you have a medical or physicians network in place for worker’s comp. claims? € Yes € No
If yes, describe in detail: ______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
10. Auto/Fleet Exposures (Complete if auto is not submitted with the workers’ compensation.)
a. Number of Drivers: _____________________________________________________________________________________________
b. Number of and types of vehicles: _______________________________________________________________________________
c. How are vehicles used? ________________________________________________________________________________________
d. What time of the day are vehicles used? ________________________________________________________________________
e. Who is allowed to drive vehicles? _______________________________________________________________________________
f. How often are MVR’s pulled on all drivers? ______________________________________________________________________
g. Describe MVR policy as it relates to vehicle usage: _______________________________________________________________
________________________________________________________________________________________________________________
h. Are vehicles taken home? € Yes € No
If yes, what limitations are in place for personal use? ______________________________________________________________
i. Is there a maintenance program? € Yes € No
WAIVER SUBROGATION – Provide the names, addresses & class codes/payroll of all contracts requiring a waiver of subrogation.
____________________________________________________________________________________________
____________________________________________________________________________________________
Group Medical 401K Other ________________
ARF 5257 (AL) 010721 Page 5 of 6
RSGprograms.com
Crime/Employee Dishonesty Questionnaire
(Please complete only if desired.)
1. Do you have an audited financial statement prepared annually? € Yes € No
€ Yes € No
2. Are internal financial statements prepared?
If yes, how often are they reviewed by the owner? ________________________________________________________
3. Describe your “Separation of Duties” and “Countersignature” procedures: _________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
4. Indicate the number of employees who handle, have custody or maintain records of money, securities or
other property: ___________________________________________________________________________________________
5. Are officer-shareholders active in the day to day oversight of business operations? € Yes € No
6. Do employees who reconcile the bank statement also:
Make deposits? € Yes € No Make withdrawals? € Yes € No Sign Checks? € Yes € No
7. Is countersignature of checks required? € Yes € No
If yes, what is the dual signing limit? _______________________________________________________________
8. Is segregation of duties practiced in the following areas:
Inventory management? € Yes € No Wire transfer receipts and payments? € Yes € No
Purchase order approval and payment? € Yes € No Vendor approval? € Yes € No
Oversight of blank check stock? € Yes € No Payroll? € Yes € No
Retail checks and Credit Card receipts? € Yes € No Cash receipts? € Yes € No
9. Are all incoming checks stamped “for deposit only” immediately upon receipt? € Yes € No
10. Are inventory records computerized? € Yes € No
Is a physical count of inventory conducted at least annually? € Yes € No
11. Are the duties of computer programmers and operators separated? € Yes € No
12. Are computer passwords changed frequently? € Yes € No
13. For new employees, do you perform any of the following types of background checks:
Prior employment? € Yes € No Education? € Yes € No Criminal history? € Yes € No
Drug testing? € Yes € No Credit history? € Yes € No
14. Are the controls indicated in 5-13 above imposed at all locations? € Yes € No
If no, please explain exceptions.
15. List all Crime/Fidelity Losses in the last three years:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
16. Please indicate the coverages, limits, and deductibles desired:
€ $25,000 limit, $1,000 deductible
€ $50,000 limit, $1,500 deductible
€ $75,000 limit, $2,500 deductible
€ $100,000 limit, $5,000 deductible
€ Other _____________________
17. List any qualified benefit plans
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
18. Are you interested in Fiduciary Liability Coverage? € Yes € No
If yes, please attach Form 5500’s for each plan to be covered.
19. Current Fidelity Carrier? ________________ Premium? ________________
Limits? ________________ Deductible? ________________
ARF 5257 (AL) 010721 Page 6 of 6
RSGprograms.com
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Alarm Installation & Monitoring Application*** (All Risks, Ltd)

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Completed 20 January 2021

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