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Alarm General Liability Incl E & O


This application does not bind the applicant nor the company to complete the insurance , but it is agreed that the information 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 and insurance company or other person files and 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 subject such person to criminal and civil penalities: NOT APPLICABLE IN NEBRASKA,OREGON AND VERMONT.

NOTICE TO COLORADO APPLICANTS: Its is a unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the 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.


Company Name *
Street Address
City *
State / Province *
ZIP / Postal Code *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Company Owner *
First Name *
Last Name *
Year Business Started *
Years of Alarm Experience *
Type Of Business Entity
Do you currently have insurance?
Current Insurance Provider
Current Policy End Date
/ /
Limit of Liability *


Umbrella Liability
Services Provided











Monitoring Operations Provided By:
Does Applicant Install Alarms In Hospitals, Nursing Homes,Transporation facilities detention or correction facilities *

Does Applicants Install or monitor alarms at chemical,fertilizer, or petrochemical facilities *

Does applicant install monitor metal, chemical or explosive detention devices at transporat ion facilities,federal buildings or post office mailrooms *

Does applicant have off shore exposures *

Does applicant have workers compensation coverage *

Does Applicant install,service or repair fire suppression systems *

Does applicant limit his liability to a stated amount on this standard alarm contract *

During the past 3 years has any company ever canceled,declined or refused to issue similar insurance *

Does applicant have other business ventures for which coverage is not requested *

How many Owners Technicians *
Alarm Payroll Excluding Owners
Gross Sales $ *
Cost of Subs *
Percentage of sales Residential *
Any General Liability Claims last 3 years *

Claim Paid Amount *
Date of Loss *
Does Applicant Install Alarms in cars, mobile equipment, boats or aircraft ? *

Medical Alarm Sales
Other Coverages Quotes Needed:





How did you find Us ? *
How Soon Is Coverage Needed If Quote Is Acceptable
/ /
Remarks
Remarks
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.


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