Fillable Security Guard Application (All Risks, Ltd)

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Security Guard Application (All Risks, Ltd)

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Will the principals perform Guard/Investigative Operations?
National Specialty Programs
Toll-Free: 800-
366-5810 • Fax: 410-828-8179
Contact us: programs@ryansg.com
Security Guard Application
General Information (Complete All Lines)
1. First Named Insured: ________________________________________________________________________________________
Additional DBA Names: ______________________________________________________________________________________
2. Physical Address: ___________________________________________________________________________________________
Street Name City/County/State/Zip
3. Mailing Address: ____________________________________________________________________________________________
Street Name City/County/State/Zip
4. Insured Email Address: _______________________________________________________________________________________
5. Inspection Contact: _________________________________________ Phone: _____________________________
Audit Contact: ________________________________________________ Phone: _____________________________
Claims Contact: _______________________________________________ Phone: _____________________________
6. Telephone: ____________________________ Fax: ________________________________
7. Website: ________________________________________________________ FEIN: _______________________________
8. Date established: __________________ License No. _______________________________
Sole Proprietor Partnership Corporation Other: _________________________
9. Policy proposed effective date: ____________________ to ____________________
10. Current coverage expires/expired on: ____________________
11. Applicant Classification: Security Service Investigations Consulting Alarm Service & Monitoring
12. In regards to your clients, do you assume any duties not related to security (i.e. janitorial, maintenance,
housekeeping, etc.)? Yes No
If yes, please explain: _______________________________________________________________________________________
_________________________________________________________________________________________________________
13. Provide the names of your five (5) largest revenue producing clients, and type of facility:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
14. Are the majority of your clients under contract? Yes No
15. Do you subcontract work? Yes No
If yes, do you require certificates and/or proof of Errors & Omissions and Commercial General Liability Insurance? Yes No
16. Training Program consists of: Written Manual On Job CPR Report Writing Films
Powers of Arrest Firearms Classroom Other: ____________________
What background do the principals of this organization have in the Security Industry? ___________________________________
_________________________________________________________________________________________________________
*Please attach resume if no prior coverage.
Security Guard Application 010721 Page 1 of 6
Yes No
RSGprograms.com
Security Guard Application 010721 Page 2 of 6 RSGprograms.com
17. Pre-employment screening procedures consist of: Polygraph Prior Employer Contacted
Criminal Background Drug Screening Fingerprint Check Driving Record
Psychological Test Personal References Other: _________________________________________
18. Total number of Guards:
Full-Time
Part-Time
Armed
Unarmed
Supervisors
19. Employee Pay Scale (Hourly):
Minimum
Maximum
Average
Armed
Unarmed
Supervisors
20. Total number of annual guard hours: Armed: _____________ Unarmed: _______________
21. Are all armed employees licensed by the state to carry firearms? Yes No
22. Do you anticipate using dogs? *Must be leashed not to exceed 6ft. Yes No
If yes, number of dogs used with handlers: ____________________ Without handlers: __________________
What purpose will the dogs be used? Bombs Drugs Airports Other: ____________________
23. Please complete below if requesting Auto, Umbrella, or Workers’ Compensation coverage.
a. Are applicants’ MVRs reviewed upon hire and annually thereafter? Yes No
b. Are standards for acceptable drivers in place? Yes No
c. Is an action plan in place if acceptability standards are not met? Yes No
d. Are all drivers between 21 and 70 years old? Yes No
e. If over 70, are medical certificates available stating that he/she has no medical issues that would preclude him/her from
driving? Yes No
f. Does the insured have an acceptable Fleet Safety Program in place? Yes No
g. Is a Vehicle Maintenance Program in place? Yes No
h. Is personal usage of company vehicles prohibited? Yes No
i. Does the insured have a written personal use policy in place? Yes No
j. Is the original cost new of all vehicles less than $75,000? Yes No
If you answered “No” to any of the above, please explain: _________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
24. Any jobs with post orders other than observe and report? Yes No
If yes, please describe: ______________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Security Guard Application 010721 Page 3 of 6
RSGprograms.com
LIST ANNUAL PAYROLL SEPARATELY BY CATEGORY
ARMED PAYROLL
UNARMED PAYROLL
TOTAL:
Security Guard Application 010721 Page 4 of 6
Specific Underwriting Questions
If any payroll is included for any of the categories marked with an asterisk* on the previous page, please answer the following
specific underwriting questions. You only need to answer questions in applicable categories.
Retail
1. On a separate page, please list the name and address for all retail contracts (required).
2. Do the post orders at any location include Apprehension/Detention duties? Yes No
3. Is the insured contracted to work during store hours or after hours only? During Hours After Hours Only
4. How long has the insured had each contract? ______________________________
Apartments
1. On a separate page, please list the name and address for all residential contracts.
2. Do any of the apartments provide any subsidized housing? Yes No
3. How long has the insured had this contract? ______________________________
4. What are the guard hours for each location? ______________________________
5. What are the post orders? Please provide a copy of the post orders for this type of work.
Low Income Housing, Senior Subsidized Housing
1. On a separate page, please list the name and address for all residential contracts.
2. Is this a senior only subsidized location? Yes No
3. How long has the insured had this contract? ______________________________
4. What are the guard hours for each location? ______________________________
5. What are the post orders? Please provide a copy of the post orders for this type of work.
Condo Associations, HOAs, High End Gated Communities
1. On a separate page, please list the name and address for all residential contracts.
2. How long has the insured had this contract? ______________________________
3. What are the guard hours for each location? ______________________________
4. What are the post orders? Please provide a copy of the post orders for this type of work.
Conventions
1. Where are the conventions held? ______________________________________________________________________________
2. What are the types of conventions? ____________________________________________________________________________
3. Projected attendance (approximate # of people on average)? ______________________________
4. What are the guard post orders? Please provide a copy of the post orders for this type of work.
Hospitals
1. Is the insured contracted to do anything other than lobby security and/or parking lot security? Yes No
If so, what? ___________________________________________________________________________________________
2. Do the insured’s post orders include any patient interaction/monitoring? Yes No
3. How long has the insured had the contract? ______________________________
Escort/Bodyguard
1. Are services performed for any high profile people or celebrities? Yes No
2. What are the duties/services provided? _________________________________________________________________________
3. Do guards travel out of state? Yes No Out of the country?
Yes No
RSGprograms.com
Security Guard Application 010721 Page 5 of 6
Fast Food
1. On a separate page, please list the name and address for all retail contracts.
2. Do the post orders at any location include Apprehension/Detention duties? Yes No
3. When is the insured contracted to do work? During Hours After Hours Only
4. How long has the insured had each contract? ______________________________
Hotel/Motel
1. On a separate page, please list the name and address for all contracts.
2. Do any of the post orders include anything other than lobby and parking lot security? Yes No
3. Are there bars/lounges on premises? Yes No
4. How long has the insured had each contract? ______________________________
Traffic Control
1. Where is the traffic control work being performed? ________________________________________________________________
2. Is there any work on open roads or highways? Yes No
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 names of carriers, premiums paid, limits, sales, deductibles, and loss runs for the past 5 years.
Year
Year
Year
Year
Year
Carrier
Premium
Payroll
Hours
Deductible
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. Please be 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 which
may give rise to a future claim?
Yes No
RSGprograms.com
Security Guard Application 010721 Page 6 of 6
RSGprograms.com
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 MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE
ACT, WHICH IS A CRIME BY SIGNING THIS APPLICATION, THE SIGNOR WARRANTS THAT TO THE BEST KNOWLEDGE ALL
INFORMATION GIVEN IS TRUE AND ACCURATE.
_____________________________________ _____________________________________ _____________________
Insured Name (Type or Print) Insured 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.
_______________________________ _______________________________ _________________ ______________
Producer Name (Type or Print) Producer Signature Date License #
UMBRELLA QUESTIONNAIRE
Please complete only if requesting umbrella coverage.
**ACORD Application & 5 Years of Auto Loss Runs required for Umbrella coverage.
1. With the exception of lienholders, 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. Are any vehicles leased to others? Yes No
4. Are any vehicles customized, altered or have special equipment? Yes No
5. Do operations involve transporting hazardous material? Yes No
6. Are any vehicles used by family members or non-employees? Yes No
7. Does the applicant have a specific driver recruiting method? Yes No
If yes to any of the above questions, please explain: ______________________________________________________________
_________________________________________________________________________________________________________
WORKERS’ COMPENSATION
Information Required with Submission (Please attach):
ACORD Workers’ Compensation Application
5 Years Currently Valued Loss Run Statements
Experience Modification Worksheet
Risk Identification Number for the NCCI or Appropriate State Rating Bureau or State Fund
1. Is the current coverage now in Assigned Risk, State Fund or Voluntary Market? Yes No
2. Has any insurance carrier canceled or refused to renew within the past 3 years? Yes No
If yes, please explain: _______________________________________________________________________________________
3. Employee Benefits Program: Group Medical 401k Other: __________________________________
4. Who is responsible for safety? _________________________________________________________________________________
WC WAIVER OF SUBROGATION
Blanket Individual
Please provide the names, addresses and class codes/payroll of all contracts requiring an individual waiver of subrogation.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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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Security Guard Application (All Risks, Ltd)

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Completed 20 January 2021

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