RISK SPECIALISTS COMPANY 200 STATE STREET, BOSTON, MA ALARM CONTRACTORS PROGRAM

Transcription

1 RISK SPECIALISTS COMPANY 200 STATE STREET, BOSTON, MA ALARM CONTRACTORS PROGRAM PART I: COMPREHENSIVE GENERAL LIABILITY INCLUDING ERRORS AND OMMISSIONS COVERAGE 1. NAME AND PREMISES ADDRESS: MAILINGS ADDRESS (IF DIFFERENT): ADDITIONAL LOCATIONS: YES NO (IF YES, ATTACH SEPARATE SCHEDULE) 2. CONTACT PERSON: PHONE: FAX: 3. YEARS IN BUSINESS: (If less than 3, please describe qualifications/years of experience) 4. NAME OF SUBSIDIARIES OWNED / CONTROLLED / MANAGED BY APPLICANT 5. TYPE OF OWNERSHIP: Corporation Partnership Individual Other (describe) 6. DESCRIBE SCOPE OF COMPANY OPERATIONS: 7. REVENUE AND PAYROLL: Total Annual Receipts: $ Total Annual Payroll: $ Breakdown of Revenue: Installation & Service (Alarm & Security) $ Monitoring $ Phone Networks $ Video $ Wireless Communications $ Cable Connections $ Internet Connections $ Cable Connections $ Other Installation Operations (Describe & give revenue for each): Retail or Wholesale Telecommunication Sales Operations (describe & provide Sales): Other Operations not Installation or Sales of Goods (provide Revenues): Sub-Contracting: Installation $ Monitoring $ Alarm Contractors.doc 1 of 5

2 8. BREAKDOWN OF INSTALLATION OPERATIONS (must equal 100%): A. COMMERCIAL: % RESIDENTIAL: % INSTITUTIONAL: % OTHER (DESCRIBE): % % TOTAL: 100 B. HAS THE RISK DONE OR INTEND TO DO ANY NEW CONSTRUCTION IN CONDOMINIUMS, TOWNHOUSES OR RESIDENTIAL TRACT HOUSING OF TEN UNITS OR MORE. [ } YES [ ] NO 9. PRODUCTS: A. Are Products used UL or Factory Mutual Approved? Yes No B. # of accounts where UL certificates are required: C. Do you sell or manufacture under your own label? Yes No **If yes, please explain under separate attachment. 10. MONITORING OPERATIONS: A. Direct Monitoring: # of clients Sub-Contracted Monitoring: # of clients Name of Sub-Contacting Co.: ** Enclose copy of Contract ** Enclose Certificate of Insurance from sub-contractor naming applicant as Additional Insured B. Is access area restricted & monitored? Yes No Are false alarms recorded? Yes No What measures does the Co. use to reduce False Alarms? C. LOCAL: % CENTRAL STATION: % # OF CENTRAL STATION SUBSCRIBERS a) Residential % b) Commercial % 11. EMPLOYEES: A. # of employees: (1) Full time (2) Part Time: B. Are training programs required? Yes No (If yes, please explain) C. Are prospective employees screened? Yes No (If yes, please explain) D. Does the Applicant provide employee benefits? Yes No E. Does the Applicant carry a business automobile policy? Yes No 12. LOSS HISTORY: (Describe all claims in the past 5 years / attach a separate sheet if necessary) YEAR NATURE OF CLAIM RESERVE AMOUNT PAID AMOUNT DATE CLOSED ** REQUIRED - ATTACH COMPANY LOSS RUNS RECENTLY VALUED ** Alarm Contractors.doc 2 of 5

3 13. LIMITS OF LIABILITY / LIQUIDATED DAMAGES CLAUSE: Does the Applicant use standard contracts on every job? Yes No Do the Applicant s contracts contain a Limits of Liability Clause (Liquidated Damages)? Yes No REQUIRED: REVIEW / APPROVAL OF ALL STANDARD COMPANY CONTRACTS, WHICH MUST CONTAIN A LIMITS OF LIABILITY / LIQUIDATED DAMAGES CLAUSE *** PLEASE ATTACH COPIES. 14. PRESENT COVERAGE: GENERAL LIABILITY A. CARRIER: POLICY TERM B. LIMITS: / OCCURRENCE / AGGREGATE C. DEDUCTIBLE: PREMIUM: D. RETROACTIVE DATE: E. CLAIMS MADE OR OCCURRENCE POLICY: F. IS PROFESSIONAL LIABILITY COVERAGE INCLUDED?: YES NO G. RATING BASIS: ANNUAL RECIEPTS $ PAYROLL $ 15. COVERAGE DESIRED: LIMITS DESIRED DEDUCTIBLE DESIRED $ 500,000 / 500,000 $500. $1,000. $1,000,000 / 1,000,000 $2,500. $5,000 $1,000,000 / 2,000,000 OTHER $ 16. AUTO EXPOSURE: TYPE NUMBER RADIUS (L=LOCAL 0-50; I = INTERMEDIATE ; LH = OVER 100) PPT VAN/P/U LT TRK MED TRK HVY TRK OTHER (EXPLAIN) 17. DOES RISK DO ANY OF THE FOLLOWING (IF YES PLEASE EXPLAIN) (a) Design or Consulting work Yes No (b) Software Design & Consulting Yes No (c) Processing or conversion of data of others Yes No EXPLANATION OF YES ANSWERS TO ABOVE: Alarm Contractors.doc 3 of 5

4 PART II (OPTIONAL PROPERTY COVERAGE SECTION): BUILDING & PERSONAL PROPERTY, BUSINESS INCOME, INLAND MARINE COVERAGE 1. PREMISES NO. 01 / BUILDING NO. 01: A. SUBJECT OF AMOUNT COINS % VALUATION INFLATION DEDUCTIBLE INSURANCE CAUSE OF LOSS GUARD B. CONSTRUCTION TYPE: Wood Frame: Brick/Metal: Fire Resistive: PROTECTION CLASS (1-10): ADJACENT EXPOSURES: Left Exposure & Distance: Right Exposure & Distance Rear Exposure & Distance BURGLAR / FIRE PROTECTION: Burglar Alarm Type: Central Station: Yes No Fire Protection: Type (Sprinklers, Standpipe, CO2/Halon) Manufacturer % Of area covered C. ARE LOSS CONTROL / HOUSEKEEPING MEASURES USED? Yes No (If yes, please explain) **** (FOR ADDITIONAL LOCATIONS, PLEASE ATTACH A SEPARATE SCHEDULE)**** 2. INLAND MARINE COVERAGE, FOR CONTRACTOR S EQUIPMENT: TOTAL VALUE OF ALL CONTRACTOR'S EQUIPMENT $ **(REQUIRED: PLEASE ATTACH A SCHEDULE OF ALL EQUIPMENT TO BE COVERED)** ADDITIONAL INTERESTS: Name & Address: Type of Interest: Certification Required (if any): PLEASE INCLUDE ACORD APPLICATION IF NECESSARY Alarm Contractors.doc 4 of 5

5 ****SIGNATURE & STATE NOTICE REQUIREMENTS: (THIS SECTION CONTINUES TO PAGE 5 OF THE APPLICATION)**** 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 the cancellation of any subsequently issued policy or policies. Signature of Owner, Partner or Officer: Title: Date: NOTICE TO ARKANSAS APPLICATIONS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO COLORADO APPLICANTS: IT IS 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. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWLINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLIAM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIALTHERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: 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, 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. Alarm Contractors.doc 5 of 5