Commercial Insurance Underwriters, Inc. A Surplus Lines Agency www.ciusgf.com 901 E. Saint Louis St. #205 Springfield, MO. 65806-2537

Alarm Installation, Servicing, Monitoring, or Repair

General Liability Application

ANSWER ALL QUESTIONS - IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE

Applicant Is: Individual  Corporation   Partnership    Joint Venture   Limited Liability Company  Other 

Other Type: 

A.  Number of years in business?        Total number of employees:   

B.  Is applicant licensed?    No Yes

        If no, explain:   

C.  Estimated annual

D.  Operations of applicant (show sales and payroll for each):

Explanations from above:

E.  Does applicant do any manufacturing?    No Yes

    Does applicant sell anything under own label?    No Yes

    If the answer to either is yes, please explain:   

F.  Does applicant sell any items other than items which are installed by applicant?    No Yes

    If yes, provide listing of products sold:   

    Sales amount for these products:   

G.  Does applicant do design work for others?    No Yes

    If yes, percent of operation:    %

H.  Does applicant design systems without performing installation?    No Yes

    If yes, percent of operation:    %

I.  Does applicant install alarms in hospitals, nursing homes, transportation facilities, detention or correctional facilities?    No Yes

    If yes, provide details and sales amount:   

J.  Does applicant install alarms in hospitals, nursing homes, transportation facilities, detention or correctional facilities?    No Yes

    If yes, provide details and sales amount:   

K.  Does applicant install or monitor alarms at chemical, fertilizer or petrochemical facilities?    No Yes

L.  Does applicant install or monitor metal, chemical or explosive detection devices at transportation facilities, federal buildings or post

         office mailrooms?    No Yes

M.  Does applicant monitor for home incarceration or pretrial release?    No Yes

N.  Does applicant have Workers’ Compensation coverage in force?    No Yes

O.  Does applicant lease employees?    No Yes

P.  Does applicant have a training program?    No Yes

Q.  Does applicant subcontract work to others?    No Yes

      If yes, what type of work?  

     Are certificates of insurance obtained from ALL subcontractors?    No Yes

    (C) Any hold harmless agreements executed in favor of client.   

    with his client?    No Yes

      If yes:    What is maximum limit allowed?   

    (Not applicable in Missouri)  No Yes

Previous Insurer and Loss History:  Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior three years.

SCHEDULE OF HAZARDS

This application dos 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 any insurance company or other person files an 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 subjects such person to criminal and civil penalties.

FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

FRAUD WARNING (APPLICABLE IN THE STATE OF NEW YORK):

Any person who knowingly and with intent to defraud any insurance company or other person files an 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

NAME AND TITLE:   

APPLICANT'S SIGNATURE:____________________________________________             DATE:______________________   

PRODUCER'S SIGNATURE:____________________________________________               DATE: _____________________

NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:

----IMPORTANT NOTICE----

As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.