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SECURITY GUARDS AND RELATED OPERATIONS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GLS-APP-3s (9-16) Page 1 of 10
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
SECURITY GUARDS AND RELATED OPERATIONS 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
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Website Address:
E-mail Address: Phone No.:
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) $
Errors and Omissions Coverage (cannot exceed GL limits)
(Each Claim/Aggregate)
$
Lost Key Coverage $25,000/$25,000 (included)
Property Damage Extension $ 5,000/$25,000 (included)
Assault and/or Battery Coverage Sublimit
(included at policy limits—sublimit cannot exceed GL limits)
$
Other Coverages, Restrictions, and/or Endorsements:
$
Deductible $
GLS-APP-3s (9-16) Page 2 of 10
1. How long has applicant been in business? ............................................................................................
2. Branch offices and locations:
a.
b.
c.
3. Operations conducted in the following states:
State: Licensed with state? ................... Yes No License No.:
State: Licensed with state? ................... Yes No License No.:
State: Licensed with state? ................... Yes No License No.:
4. Total number of employees: ....................................................................................................................
5. Number of unarmed employees: Estimated Payroll: Gross Sales:
Number of armed employees: Estimated Payroll: Gross Sales:
Any armed guards in retail stores? .............................................................................................................. Yes No
Arrest authority? .......................................................................................................................................... Yes No
If yes, are any employees with arrest authority not off-duty police? ........................................................... Yes No
6. Total number of hours billed to clients annually: ..................................................................................
7. Are ALL armed personnel certified for use of firearms by a state agency or a firearms certifica-
tion school? ...............................................................................................................................................
Yes No
8. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
9. Does applicant lease employees? ........................................................................................................... Yes No
10. Does applicant subcontract any operations? ........................................................................................ Yes No
If yes:
a. Description of operations subcontracted:
b. Annual cost of subcontracted work: ......................................................................................................
c. Are all subcontractors required to carry General Liability Insurance? .................................................. Yes No
If yes, minimum General Liability limits required:..................................................................................
d. Are all subcontractors required to carry Workers Compensation Insurance? ...................................... Yes No
e. Are certificates of insurance obtained from all subcontractors? ........................................................... Yes No
f. Is applicant named as an additional insured on all subcontractors’ policies? ...................................... Yes No
g. Do written contracts contain hold-harmless agreements in favor of the applicant? ............................. Yes No
If no, explain when not required:
11. Are personnel licensed as required by state and federal agencies? ................................................... Yes No
12. Are background investigations and checks conducted on new employees? .................................... Yes No
If yes, describe procedures used for pre-employment checks:
13. Does applicant use a recordkeeping log and incident reporting log for each job? ........................... Yes No
GLS-APP-3s (9-16) Page 3 of 10
14. Does applicant have a training program for employees? ..................................................................... Yes No
If yes, describe:
Does applicant have a training manual? ..................................................................................................... Yes No
15. Does applicant use stun guns? ............................................................................................................... Yes No
16. Does applicant use animals? ................................................................................................................... Yes No
If yes:
a. Number with handlers: without handlers:
b. Are animals used to detect guns or bombs?......................................................................................... Yes No
c. Are animals used to detect drugs? ....................................................................................................... Yes No
17. Number of supervisors: ............................................................................................................................
Describe duties:
Do the supervisors perform investigative or guard duties? ......................................................................... Yes No
18. List the applicant’s ten (10) largest clients. Indicate type of operation performed and duties involved:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
19. Does applicant conduct any operations involving nuclear power plants? ......................................... Yes No
20. Additional Insured Information:
Name
Address
Interest
Any government entity listed as an additional insured?....................................................................... Yes No
If yes, explain:
21. During the past three years, has any company canceled, nonrenewed, declined or refused
similar insurance to the applicant? (Not applicable in Missouri) ............................................................
Yes No
If yes, explain:
GLS-APP-3s (9-16) Page 4 of 10
22. Provide private investigation annual payroll by listed operation (include subcontractor payroll not covered by
other insurance):
Private Investigation
Armed
Payroll
Unarmed
Payroll
Arson investigation
Computer fraud
Corporate—employee dishonesty
Credit pre-employment screening
Domestic
Insurance claim investigation
Legal
Missing person
Records check
Surveillance—describe:
Undercover operations
Other—describe:
23. Provide guard services annual payroll by listed operation including parking lot security (include subcontrac-
tor payroll not covered by other insurance):
Guard Services
Armed
Payroll
Unarmed
Payroll
Airports
Abortion clinics or family planning centers
Alarm monitoring:
Burglary/fire
Medical emergency
Alarm response
Baggage handling security
Banks
Bouncers or doormen at restaurants, night clubs, discos, bars/taverns
Churches
Construction sites
Convenience stores
Criminal detention centers
Fast food restaurants
Ground transportation terminals
Hospitals
Hotels/Motels
GLS-APP-3s (9-16) Page 5 of 10
Guard Services
Armed
Payroll
Unarmed
Payroll
Housing:
Apartments
Condominiums or townhouses
Homeowners associations
Private residences
Immigration detention centers
Manufacturing
Marijuana dispensaries or growing facilities
Mines
Movie theaters
Motels/hotels
Offices
Parking lot security
Retail Operations:
Clothing stores
Department stores
Liquor stores
Shopping centers/malls
Supermarkets
All other
Schools and universities
Special events:
Athletic events—describe type:
Concerts—describe (rock & roll, hard rock, rap, country, other):
Other—describe:
Sports stadiums or arenas
Strike work
Utility property security
Warehouses
Wharf, waterfront or seaport security
Other—describe:
GLS-APP-3s (9-16) Page 6 of 10
24. Provide miscellaneous services annual payroll by listed operation including parking lot security (include
subcontractor payroll not covered by other insurance):
Miscellaneous Services
Armed
Payroll
Unarmed
Payroll
Alarm installation, service or repair
Animal services with handler
Auto repossession
Bail bond operations
Bodyguards
Border patrol
Bounty hunters
Consulting or expert witness
Courier or escort:
Armored car service
Armed couriers
Bicycle or skate couriers
Couriers—non-negotiable
Couriers—negotiable
Courier escorts
Funeral escorts
Drug surveillance
Drug testing
Eviction operations
Firearms certification/training schools
Insurance adjusters
Parole Officers
Polygraph work
Prisoner transport
Process servers
Repossession/collection work
School crossing guards
Security consulting
Security guard school/training for others
Shopping service
Traffic control
Utility shut-off operations
Other—describe:
GLS-APP-3s (9-16) Page 7 of 10
25. Does applicant 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:
26. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
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 in the last three years
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
29. California only: Are guard cards obtained for all employees? ............................................................. Yes No
30. Please attach: a. Any descriptive advertising literature;
b. Copy of the applicant’s standard performance contract with client; and
c. Copies of all agreements in which the applicant has assumed liability.
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.
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
GLS-APP-3s (9-16) Page 8 of 10
company
GLS-APP-3s (9-16) Page 9 of 10
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 payable from in-
surance 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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
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 un-
der 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-3s (9-16) Page 10 of 10
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 NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
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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SECURITY GUARDS AND RELATED OPERATIONS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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