Create

Broker Information

Broker/Agent Name:		Broker/Agent Phone:
Broker/Agent Address:
Broker/Agent City:	Broker/Agent State:		Broker/Agent Zip:

Operations

(Please indicate the % of gross sales/receipts by type of operation (total of all services should equal 100%)

The Total Operation percent: 0

Do you install, service, or monitor fire suppression systems? Yes No	If yes % of Contracts:%
Do your employees respond to site of alarm? Yes No	If yes % of Contracts:%
Do you have a showroom? Yes No
If monitoring company, is your central station UL Listed / FM Approved / or registered with a different nationally recognized testing laboratory? Yes No

Describe all Other Services Provided:
Describe all Activities in Detail:

Training

What Certifications do you require of your employees?
Describe the training you provide for employees:
Do you have or follow a written job safety program? Yes No
Are background checks done on all employees? Yes No

Revenue and Contracts

	Payroll-Total	Gross Sales	G/L E&O Premium	Subcontract Costs
Upcoming Year	$	$	$	$

The statements and answers herein are warranted to be true and are made with the knowledge that the Company will act in reliance upon them. This request is designed to solicit information and is not a policy or policy binder on the part of the Applicant, its agency, or the Insurance Company. Any misrepresentations by the Applicant may result in denial of coverage or the cancellation of any subsequently issued policy or policies. Since this is a member benefit, you may be contacted by the ESA for membership.

Company Name:		DBA:
Address:
City:	State:		Zip:
ESA Membership Number:	Years In Business:		Current Policy Expires:
PSA Membership Number:	Requested Effective Date:		Application Type:

Contact First Name:		Contact Last Name:		Email Address:
Phone:		Fax:		Web Address:

Are you associated with a dealer program?	Yes No		If Yes, Which one?	First Alert Dealers Interlogix
Employee Benefits Liability Needed?	Yes No	FEIN:		Number of Employees:
How did you hear about Security America?			Promotion Code?
Are you IQ Certified?	Yes No	What deductible do you currently have?		$1,000 $2,500 $5,000 $25,000
Would you like a quote for higher limits? Yes No			if yes, please check any of the following		Excess Umbrella
Number of Vehicles (ONLY if obtaining an Umbrella quote):

Security/Fire Alarm Installation	%	Locksmiths	%
Security/Fire Alarm Service/Maintenance	%	Fire Sprinkler Installation/Repair	%
Monitoring, Non-Medical	%	Hood/Vent Systems Installation/Repair	%
Medical Monitoring	%	Fire Extinguisher Installation/Service	%
Security and Patrol Services, Armed	%	PERS Installation/Monitoring	%
Security and Patrol Services, Unarmed	%	Other Services (Explain Below)	%

If you monitor for others, are you named as additional insured on all subcontractor policies?	Yes No N/A
What limits do you require your subs to carry?	$
Do you require subcontractors to sign a written contract that has an indemnity agreement holding you harmless?	Yes No N/A
Do your contracts include a limitation of liability/liquidated damages clause?	Yes No
What is the dollar amount of your standard limitation?	$
Have you had any claims in the past 5 years?	Yes No
Claims Explaination:
Are your subcontractors providing you with certificates of insurance?	Yes No N/A
Percentage of accounts that have contracts:	%
Are false alarms recorded?	Yes No

Broker Information

Company Information

Operations

Training

Revenue and Contracts