Security Guard Insurance Application

If you have questions about this application, please contact:
Kevin Whaley, LIC, Vice President - Program Manager
Email - kwhaley@thecampbellgrp.com
Connie Williams - Customer Service
Direct Dial - (616) 541-1329
Fax - (800) 847-3129
Email - cwilliams@thecampbellgrp.com


*You MUST be an MCPI member to qualify for insurance. If you're not a member, please click here for more information.

Member Information 1. Name of Business or Licensee Name:
Street Address:
City:     State:     Zip Code:
Mailing Address, if different:
Additional Locations, if any:
Contact Name:   Telephone:
Fax:     Email:
2. Are you currently an active member of MCPI?: No Yes
3. Applicant is: Corporation Partnership Individual LLC
General/Errors & Ommisions/Property/Crime Application 4. Proposed Effective Date:
5. Limit of Liability: $300,000 $500,000 $1,000,000
6. Deductibles: $1,000 $2,500 $5,000
7. Total Gross Receipts:
Current Year Estimated Next Year
8. Total Payroll:
  Current Year Estimated Next Year
Guards
Investigators
Alarming
(Exclude clerical and sales stuff from above numbers)
9. Industries and services provided for your top five (5) clients:
  Industry Services Provided
1
2
3
4
5
10. Description of Operations; (Please provide approximate percentage (%) in each category.)
Category Unarmed Armed Category Unarmed Armed
Abortion Clinics Hotels/Motels/Inns/Resorts
Airports Industrial (Factories, Warehouses, etc.)
Alarm Monitoring Low Income Housing
Apartments/Condos/Co-Ops Manufacturing
Armored Cars Movies/Theaters
Arson Investigating Museums/Galleries
Banks/Office Buildings Offices
Bars/Discos/Clubs Parking Garages
Body Guard Patrol Cars
Bus/Train Terminals Repossessions
Churches Restaurants
Colleges/Universities Retail (Stores/Markets)
Concerts (Rap, Rock, etc.) Schools
Construction Sites Security Consultation
Conventions/Trade Shows Shopping Malls
Courier Escort Social Services/Clinics
Drug Searches Special Events
Executive Protection Sporting Events
Fast Food Establishments Strike Duty
Gated Communities Traffic Control
Golf/Tennis/Yacht Clubs Trucking Terminals
Governmental Contracts Waterfront/Piers/Marinas
Hospitals/Institutions Other
Describe operations for highlighted categories

11. Optional Coverage
Coverage: Limit:
Contents
Computers
Client's Property
Inside Premises Theft of Money & Securities
Outside Premises Theft of Money & Securities
Deductible $1,000

12. Number of employees:
13. Describe hiring practices and screening:
a. Fingerprinting:
b. Drug Testing:
c. Criminal Background:
d. Prior Employer:
e. Personal Interview:
f. Other:

14. Guard Training:
a. Classroom with Instruction Yes No
b. On the Job (supervised) Yes No
c. Films Yes No
d. Written Material Yes No
15. Approximate number of Employees per Supervisor:
16. We recommend Employees Practice Liability: Yes No
17. Canine Operations:
a. Number of Guard Dogs
b. Number of Contraband Dogs
18. Do employees use their own vehicles in your operation? Yes No
19. Describe all claims against you, including amount paid or held in reserve over the past five (5) years:

Current Carrier Information: General Liability Policy Information:
Insurance Company Effective Dates Policy Limits Exposure Base Rates Premium

20. Do you have a deductible? Yes No
Amount
21. Has any carrier ever cancelled or refused to renew your policy? Yes No
If yes, describe:

22. Other Coverages Desired (attach appropriate ACORD form applications)
Property:

Crime:

Hired and Non-Owned Auto:


Disclosure Authorization/Declarations

WARNING NOTICE (MICHIGAN): Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

The undersigned Applicant authorizes the Company, its agents, and representatives to secure claims information from my current and previous insurance carriers.

THE UNDERSIGNED DECLARES THAT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE SIGNING OF THIS APPLICATION DOES NOT BIND THE UNDERSIGNED TO PURCHASE INSURANCE, NOR DOES REVIEW OF THE APPLICATION BIND THE INSURER TO ISSUE A POLICY. IT IS AGREED, HOWEVER, THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED.

Applicant Signature:

Date:

The undersigned agent or broker additionally agrees to be responsible for any earned premium developed on any policy issued based on this application.

Agent or Broker Signature:

Date:

I would like to elect or reject Terrorism Risk Insurance Act - if elected an additional and seperately disclosed premium will be charged on your policy. Checking the rejection box constitutes a legal waiver of coverage in the same manner as a signature.