Total Number of Employees:
| / || / |
|Policy proposed effective date (start):|
|Policy proposed effective date (end):|
Please fill out the current and previous policy year:
|Annual Revenue (sales) $|
|*Annual Payroll: $|
|Annual Paid to Subs: $|
*Employees/owners who perform private investigation services. Do not include clerical or sales payroll.
|Services provided: Please check services that you now provide or would provide if requested.|
|Do you or any of your employees carry a firearm?|
|If YES, are they licensed?|
NOTICE TO APPLICANTS:
This application must be completed in full as the quote will be based soley on the information provided. Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act. Which is a crime by initialing this application. The signor warrants that to their best knowledge all information given is true and accurate.
| Check if you agree to the terms:|