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GENERAL LIABILITY APPLICATION ALARM INSTALLATION, SERVICING, MONITORING OR (Colonial General Insurance Agency, Inc)

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GLS-APP-6s (9-16) Page 1 of 6
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
ALARM INSTALLATION, SERVICING, MONITORING OR REPAIR
GENERAL LIABILITY APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Limits of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations)
$
Products and Completed Operations Aggregate $
Personal and Advertising Injury (any one person or organization) $
Each Occurrence $
Damage to Premises Rented to You (any one premise) $
Medical Expense (any one person) $
Electronic Data Liability $10,000 $25,000 $50,000 $100,000
Errors and Omissions Coverage Each Claim
(Available up to the General Liability Limits) Aggregate
$
$
Lost Key Coverage $25,000 (included)
Property Damage Extension (CCC) Occurrence
(Included for limits equal to GL limits up to $200,000/$300,000) Aggregate
$
$
Other Coverages, Restrictions, and/or Endorsements: $
Deductible $
GLS-APP-6s (9-16) Page 2 of 6
Website Address:
E-mail Address: Phone No.:
1. Additional Insured Information:
Name Address
2. How long has applicant been in business? years. Total number of employees:
3. Is applicant licensed? ............................................................................................................................... Yes No
If no, explain:
4. Estimated annual:
a. Payroll ................................................................................................................................................... $
b. Sales ..................................................................................................................................................... $
c. Cost of subcontractors .......................................................................................................................... $
5. Advise payroll and sales for each: Payroll Sales
Burglar alarms—residential
$
$
Burglar alarms—commercial $
$
Fire alarms—residential $
$
Fire alarms—commercial $
$
Alarm monitoring operations (If any
medical alarm monitoring, show separate
sales for same.)
$ $
Monitoring, installation, servicing or repair of emergency medical alert systems or
nurse call buttons. Describe:
$ $
Other:
$
$
6. Does applicant do any manufacturing? .................................................................................................. Yes No
Does applicant sell anything under own label? ........................................................................................... Yes No
If the answer to either question is yes, please explain:
7. Does applicant sell any items other than items which are installed by applicant? ........................... Yes No
If yes, provide listing of products sold:
Sales amount for these products? ............................................................................................................... $
8. Does applicant do design work for others? ........................................................................................... Yes No
If yes, percent of operation: ......................................................................................................................... %
9. Does applicant design systems without performing installation? ....................................................... Yes No
If yes, percent of operation: ......................................................................................................................... %
10. Does applicant install alarms or phones in vehicles, mobile equipment, watercraft or aircraft? .... Yes No
If yes, explain:
GLS-APP-6s (9-16) Page 3 of 6
11. Does applicant install alarms in hospitals, nursing homes, transportation facilities, detention or
correctional facilities? ..............................................................................................................................
Yes No
If yes, provide details and sales amount:
12. Does applicant install or monitor alarms at chemical, fertilizer or petrochemical facilities? ........... Yes No
13. Does applicant install or monitor metal, chemical or explosive detection devices at transporta-
tion facilities, federal buildings or post office mailrooms? ..................................................................
Yes No
14. Does applicant monitor for home incarceration or pretrial release? ................................................... Yes No
15. Does applicant have off-shore exposures (i.e., gas and oil rigs, ships)? ........................................... Yes No
16. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
17. Does applicant lease employees? ........................................................................................................... Yes No
18. Does applicant have a training program? ........................................................................................................ Yes No
If yes, describe:
19. Does applicant install, service or repair fire suppression systems? ................................................... Yes No
20. Does applicant subcontract work to others? ......................................................................................... Yes No
If yes, what type of work?
Are certificates of insurance obtained from ALL subcontractors? ............................................................... Yes No
21. Please attach: (A) Any descriptive or advertising literature; (B) Copy of usual performance contract with cli-
ent; (C) Any hold harmless agreements executed in favor of client.
22. Does applicant limit his liability to a stated dollar amount (liquidated damages) on his standard
alarm contract with his client? .................................................................................................................
Yes No
If yes: What is maximum limit allowed? .................................................................................................... $
What percentage of contracts waive the liquidated damages clause? .......................................... %
23. During the past three years, has any company ever canceled, declined or refused to issue simi-
lar insurance to the applicant? (Not applicable in Missouri) ....................................................................
Yes No
If yes, explain:
24. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
25. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
GLS-APP-6s (9-16) Page 4 of 6
26. Schedule of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
27. Prior Carrier Information:
Year:
Year:
Year:
Carrier
Policy No.
Coverage
Occurrence or Claims Made
Total Premium
28. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior three years.
Check if no losses last three years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who 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.
GLS-APP-6s (9-16) Page 5 of 6
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or state-
ment as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or con-
ceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO LOUISIANA APPLICANTS: 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 sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: 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.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties
under state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
GLS-APP-6s (9-16) Page 6 of 6
NEW YORK FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information, or conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is
a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim
for each such violation.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
IOWA LICENSED AGENT (IF APPLICABLE):
(Applicable in Iowa only)
AGENT’S NAME: AGENT’S LICENSE NUMBER:
(Applicable to Florida agents only)
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
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Completed 22 August 2020

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