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


Umbrella Liability
Optional
Services Provided
Optional











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

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

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

Does applicant have off shore exposures
Required

Does applicant have workers compensation coverage
Required

Does Applicant install,service or repair fire suppression systems
Required

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

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

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

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

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

Medical Alarm Sales
Optional
Other Coverages Quotes Needed:
Optional





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