PSB-05 (Rev. 02/2012)
Approved by Texas Dept. of Insurance
Texas Department of Public Safety www.dps.texas.gov
Regulatory Services Division
PRIVATE SECURITY PROGRAM
CERTIFICATE OF LIABILITY INSURANCE
•
MUST USE MOST
FORM
This certificate is issued as a matter of information only and confers no rights
certificate holder.
Name of Insured
(MUST EXACTLY MATCH NAME
ON PRIVATE SECURITY FILE)
Private Security
Company
Insured’s Address
(MUST EXACTLY MATCH ADDRESS
ON PRIVATE SECURITY FILE)
City
State
(2- Digit Code)
ZIP
REMAINDER OF FORM MUST BE FILLED OUT BY THE INSURANCE AGENT
(LIMITS AND COVERAGES)
The insurance policy must contain minimum limits of $100,000 per occurrence for bodily injury and property damage, and $50,000 per occurrence for personal injury with a
minimum total aggregate amount of $200,000 for all occurrences. The below does not amend, extend or alter the coverage afforded by the policies issued.
Limits of (Commercial General) Liability:
Bodily Injury/
Property Damage
$
Personal
Injury
$
Aggregate
$
Policy
Effective
( MM/DD/YYYY)
Expiration
( MM/DD/YYYY)
Exclusions & Endorsements:
(CHECK ALL THAT APPLY)
Armed Coverage
Guard Dog Coverage
Bond Forfeiture Apprehension
Coverage
Liquor Exclusion
Government Housing Exclusion
All coverage excluded by endorsement and related to the provision of security services. (For this purpose, other forms may be attached and incorporated by reference):
Insurance Binders are NOT acceptable, as they are a temporary insurance arrangement used until a permanent policy can be issued and that for
Department purposes of Certificate of Liability Insurance a permanent policy must be currently in effect.
Chapter 1702 Occupations Code provides that insurance certificates executed and filed with the Department shall remain in force and effect until
the insurer has terminated future liability by a 10 day notice to the Private Security Program.
INSURANCE COMPANY INFORMATION (AUTHORIZED REPRESENTATIVE)
Insurance
Company
Insurance Agent/
Agency
Address
City
State
(2- Digit Code)
ZIP
Texas Insurance
License Number
Phone
( )
Insurance Agent’s Signature ___________________________________________ Date _____________________
This form and any attachments can be:
• Emailed to: RSD_Customer_Relations@dps.texas.gov
• Faxed to: (512) 424-5774 (Insurance Compliance Section)
• Mailed to: Texas Department of Public Safety
Private Security Program MSC 0242
PO Box 4087
Austin, TX 78773-0001
