Security Guard Application - Graniteins


ALL RISKS, LIMITED – National Specialty Programs10150 York Road, 5th Floor, Hunt Valley, MD 21030Toll Free: (800) 366-5810Fax: (410) 828-8179Contact us at: programs@allrisks.comwww.allrisks.comSecurity Guard ApplicationGeneral Info (Complete For All Lines)1. Name(Complete name as it should appear on the policy including Inc., Corp., Ltd., Etc.)2. Physical AddressNo.StreetCityCountyStateZip Code3. Please make certain additional locations are on ACORD forms.4. Inspection Contact Phone (Audit ContactPhone (Claims ContactPhone (5. Telephone () Fax ())))6. Website FEIN7. Date established License No. Sole Proprietor Corporation8. Policy proposed effective date to Partnership Other9. Current coverage expires/expired on10. Check limit of liability desired:11. Deductible: 1,000 300,000 2,500 5,000 500,000 1,000,000 Other Other12. Applicant Classification:Security ServiceConsultingInvestigationsAlarm Service and Monitoring13. In regards to your clients. Do you assume any duties not related to security, i.e. janitorial, maintenance,housekeeping, etc. If yes, please explain14. Provide the names of your (5) five largest revenue producing clients, and a description of your duties.15. Are the majority of your clients under contract? Yes Noa. If yes, how many include hold harmless clauses?b. Please include sample copies of your standard contracts and agreements.16. Do you subcontract work?If yes, do you require certificates and/or proof of Errors & Omissions and CommercialGeneral Liability Insurance? Yes No Yes No17. Are you named as an additional insured on the subcontractor’s policy? Yes NoARF 3095 (SG) 9/071 of 8

SECURITY SERVICE/PATROL1. What background do the principals of this organization have in the Security Industry?(Please attach resume)2. Will the principals perform Guard/Investigative Operations? Yes No3. Number of Supervisors Describe duties of Supervisors:4. Average number of guards per supervisor5. Annual guard turnover rate6. Training program consists of:Written ManualReport WritingFirearmsOn JobPowers of arrestClassroomCPRFilmsOtherDescribe your training program:7. Pre-employment screening procedures (check the following):PolygraphPrior Employer ContactedDrug ScreeningFingerprint CheckPsychological TestPersonal ReferencesCriminal BackgroundDriving RecordOtherDescribe your pre-employment screening procedures:8. Total number of guard hours billed to client(s) annually:UnarmedArmed9. Total number of Guards:Full TimePart TimeUnarmedArmedSupervisors10. Do you use any equipment or golf carts for patrol? Yes NoIf yes, how many?11. Will the public be transported?If yes, are driving records checked on drivers? Yes Yes No No12. Do you anticipate using dogs? *Must be leashed not to exceed 6ft.a. If yes, number of dogs used with handlers without handlersb. And, for what purpose will the dogs be used?BombsDrugsAirportsOther Yes No13. Are all armed employees licensed by the state to carry firearms?If yes, how often will they have to be re-certified? Yes No14. Employee Pay scale (Hourly)MinimumMaximumAveragea. Supervisorsb. Unarmed Guardsc. Armed Guards15. Please provide Total Payroll and Billable Hours for the past five years:YRYRYRTotal PayrollTotal Billable HoursARF 3095 (SG) 9/07YRYR2 of 8

-LIST ANNUAL PAYROLL SEPARATELY BY CATEGORYARMED PAYROLLUNARMEDPAYROLLSUPERVISORYGUARD SERVICESAirports (describe operations)Banks or other financial institutionsConstruction or Demolition SitesConventionsEscort Service/Body Guard ServiceFast Food RestaurantsGovernment Contracts (office building, courts, military base)Hotels/MotelsHousing/Residential – Mid/High IncomeHousing/Residential – Low Income/HUDIndustrial (warehouses, factories)Institutions (schools, hospitals, other )Liquor Establishments (bars, restaurants, other )Malls/Theaters/ArcadesOffice BuildingsPatrol Cars(alarm response, patrol, other )Retail (parking lots, outside patrol, other )Retail (shoplifting, surveillance, inside, other )Special Events (sports, concerts, other )Strike WorkTraffic ControlUtilities (water, electrical, nuclear)Other- DescribeTRANSPORTATION SERVICES Armored Car ATM Services Courier (describe commodity transported) Other- DescribePRIVATE INVESTIGATIONS Auto Repossession Bank Checks (pre-employment screening) Body Guard Protection Bounty Hunter Computer Fraud Criminal Divorce/Domestic Executive Protection General Background Checks Missing Persons Polygraph Process Serving Psychological Stress Evaluator Security Consultation Other- Describe OTHER Clerical Outside Sales Other- DescribeTOTALARF 3095 (SG) 9/073 of 8

Additional CoveragesCHECK ALL THAT APPLYAdditional InsuredsWaiver of SubrogationPrimary WordingIndividualIndividualIndividualPer Project AggregateStop GapBlanketBlanketBlanketEmployee Benefits LiabilityHired/Non-owned AutoCurrent General Liability Information1. Please provide name of carriers, premiums paid, limits, sales, deductibles, and loss runs for the past 5 years.YRYRYRYRYRCarrierPremiumPayrollDed/SIRLosses Yes No2. Has any company canceled or declined to renew in the past 5 years?If yes, please explain3. Has the insured ever had a lapse in coverage? Yes NoIf yes, please explainClaim Information1. Make sure to attach 5 years of currently valued loss runs. (Valued no more than 3 months from date ofapplication)2. Do you require staff to report all unusual incidents and are all incident reports reviewed byManagement? Yes No3. Do you have any knowledge concerning any incidents that have occurred prior to the dateof this application which may give rise to a future claim? Yes NoALL RISKS, LTD.NOTICE TO APPLICANTS: THIS APPLICATION MUST BE COMPLETED IN FULL AS THE QUOTE WILL BE BASEDSOLELY ON THE INFORMATION PROVIDED, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUDANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE CONTAINING FALSEINFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACTMATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME BY SIGNING THISAPPLICATION, THE SIGNOR WARRANTS THAT TO THEIR BEST KNOWLEDGE ALL INFORMATION GIVEN IS TRUEAND ACCURATE.Name (type or print)SignatureDateNOTICE TO PRODUCERS: THE PRODUCER HEREBY WARRANTS THAT THE INFORMATION CONTAINED IN THISAPPLICATION IS TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE.Name (type or print)SignatureDateLicense #ARF 3095 (SG) 9/074 of 8

Optional Coverages(please attach an ACORD application)PropertyBusiness AutoCrime/Employee DishonestyContractors EquipmentWorkers CompensationEmployment Related PracticesEDPUmbrella/ExcessUmbrella/Excess Questionnaire(Please complete only if desired.)Explain all “Yes” responses.1. With the exception of leinholders, are any vehicles not solely owned by and registeredto the applicant? Yes No2. Do over 50% of the employees use their autos in the business? Yes No3. Is there a vehicle maintenance program in operation? Yes No4. Are any vehicles leased to others? Yes No5. Are any vehicles customized, altered or have special equipment? Yes No6. Do operations involve transporting hazardous material? Yes No7. Any vehicles used by family members or non employees?If so, please identify in remarks. Yes No8. Does the applicant obtain MVR verifications? Yes No9. Does the applicant have a specific driver recruiting method? Yes No10. Are any drivers not covered by Workers Compensation? Yes No11. Any vehicles owned but not scheduled on this application? Yes NoRemarks:ARF 3095 (SG) 9/075 of 8

WORKERS’ COMPENSATIONInformation Required with Submission: (Please attach)1. ACORD Workers’ Compensation application2. Location Coding – see attached pages3. Financials for accounts over 100,0004. Insurance Carrier Premium and Loss statements which are currently valued (5 years required).5. Drivers schedule: Names, Dates of Birth & Driver’s License Number required.6. Experience Mod. Worksheet7. Risk Identification Number for the NCCI or Appropriate State Rating Bureau or State Fund:1. Annual employee turnover rate %2. Is the current coverage now in Assigned Risk, State Fund or Voluntary Market? Yes No3. Has any insurance carrier canceled or refused to renew within the past 3 years? Yes NoIf yes, please explain4. Do you report all WC claims, regardless of payment having been made on the claim? Yes NoIf no, please explain:5. Employee Benefits Program:Group Medical401KOtherDescribe your Employee Benefits Program:6. Do you have a transitional duty (light duty) program? Yes NoIf yes, describe:7. Who is responsible for safety?8. Do you have a formal safety committee? Yes NoIf yes, how frequently does it meet and who attends?9. Do you have a medical or physicians network in place for worker’s comp. claims? Yes NoIf yes, describe in detail:10. Auto/Fleet Exposures (Complete if auto is not submitted with the workers’ compensation.)a. Number of Drivers:b. Number of and types of vehicles:c. How are vehicles used?d. What time of the day are vehicles used?e. Who is allowed to drive vehicles?f. How often are MVR’s pulled on all drivers?g. Describe MVR policy as it relates to vehicle usage:h. Are vehicles taken home? Yes NoIf yes, what limitations are in place for personal use?i. Is there a maintenance program? Yes NoWAIVER SUBROGATION – Provide the names, addresses & class codes/payroll of all contracts requiring a waiver ofsubrogation.ARF 3095 (SG) 9/076 of 8

If the Insured has no exposure to any of the High Profile Locations,please note “no exposure, and sign/date the form.WCM Workers CompensationHigh Profile locations / ExposuresLocation / Exposure TypeAirportsPublic Transportation (Incl. rail, subway stations)YesCommentsMonuments & other historically significant loc.Convention CentersMajor Religious StructuresStadiums, Arenas or Sporting ComplexesMuseums / Aquariums/ ZoosStock Exchanges or Financial CentersNationally Recognized Hospitals/ Medical CentersAmusement Parks (high profile)"Marquis" buildingsUtilities / Energy Generating StationsRefineries / Fuel DepotsDamsHazardous Chemical ManufacturingWeapons / Defense ManufacturingMilitary Bases or LocationsMajor CasinosMail Handling or DeliveryHigh-Rise BuildingsTier 1: Nationally recognized (e.g., Sears Tower)Tier 2: Over 35 storiesTier 3: Between 20 and 35 storiesOther Specialty SituationsExample: Olympic Venues, other Special EventsSignature:ARF 3095 (SG) 9/07Date:7 of 8

Crime/Employee Dishonesty Questionnaire(Please complete only if desired.)1. Do you have an audited financial statement prepared annually? Yes No2. Are internal financial statements prepared? Yes NoIf yes, how often are they reviewed by the owner?3. Describe your “Separation of Duties” and “Countersignature” procedures:4. Indicate the number of employees who handle, have custody or maintain records of money, securities orother property:5. Are officer-shareholders active in the day to day oversight of business operations?6. Do employees who reconcile the bank statement also:Make deposits? Yes NoMake withdrawals? Yes No Yes NoSign Checks? Yes No7. Is countersignature of checks required? Yes NoIf yes, what is the dual signing limit?8. Is segregation of duties practiced in the following areas:Inventory management? Yes NoWire transfer receipts and payments?Purchase order approval and payment? Yes NoVendor approval?Oversight of blank check stock? Yes NoPayroll?Retail checks and Credit Card receipts? Yes NoCash receipts? Yes No Yes No Yes No Yes No9. Are all incoming checks stamped “for deposit only” immediately upon receipt? Yes No10. Are inventory records computerized?Is a physical count of inventory conducted at least annually? Yes Yes No No11. Are the duties of computer programmers and operators separated? Yes No12. Are computer passwords changed frequently? Yes No13. For new employees, do you perform any of the following types of background checks:Prior employment? Yes NoEducation? Yes NoCriminal history? YesDrug testing? Yes NoCredit history? Yes No No14. Are the controls indicated in 5-13 above imposed at all locations?If no, please explain exceptions. Yes No15. List all Crime/Fidelity Losses in the last three years:16. Please indicate the coverages, limits, and deductibles desired: 25,000 limit, 1,000 deductible 50,000 limit, 1,500 deductible 75,000 limit, 2,500 deductible 100,000 limit, 5,000 deductible Other17. List any qualified benefit plans18. Are you interested in Fiduciary Liability Coverage?If yes, please attach Form 5500’s for each plan to be covered.19. Current Fidelity Carrier?Limits?ARF 3095 (SG) 09/07 Yes NoPremium?Deductible?8 of 8

Security Guard Application 1. Name _ (Complete name as it should appear on the policy including Inc., Corp., Ltd., Etc.) 2. Physical Address _ . Employee Pay scale (Hourly) Minimum Maximum Average a. Supervisors b. Unarmed Guards c. Armed Guards 15. Please provide Total Payroll and Billable Hours for the past five years: