Alarms Insurance Quick Quote Form from AMIS Insurance

Business & Contact Information

First Name *

M.I.

Last Name *

Business Name *

Website *

Yes No

Do you operate from a residence?

NOTE: Business address must be a street address - NO PO BOXES.

Business Street Address *

City *

State *

Zip Code *

Mailing Address (If different)

If both addresses are the same, please leave blank.

City

State

Zip Code

Email Address *

Business Phone *

- -

Home Phone

- -

Mobile Phone

- -

Fax Number

- -

Information About Your Business

State License Number *

Legal Entity Type

Corporation

Individual

Partnership

Limited Liability Corp (LLC)

Other

If Other, Explain:

Date Established *

Years of Experience

Brief Details of Experience *

Five Largest Clients & Duties *

Yes No

Do you have a brochure?

Yes No

Do you use a written contract?

Selecting "Yes" will reveal additional fields below.

Yes No

Do you belong to any associations?

Selecting "Yes" will reveal additional fields below.

Employment / Training

Pre-Employment Screening Procedure (check all applicable)

Background Check

Drug Screening

MVR

Personal Reference

Polygraph

Prior Employment Check

Psychological

Training Program Consists Of (check all applicable)

CPR

Firearms

On the Job

Powers of Arrest

Report Writing

Use of Force

Written Manual

Other

Operations

Percentage of Operations *

Please enter the percentage for each activity.

Total must equal 100%

Operation Total:

0%

% Alarms *

% Safety *

% Other *

Please describe "Other" operations:

Payroll / Receipts

Payroll & Receipts Breakdown

Installation

Manufacturing

Sales / Dist.

Service

Other

Payroll $

Receipts $

Payroll / Subcontractor's Costs / Monitoring

Total Projected Annual Payroll (Excluding Admin, Sales, and Clerical) *

$

Total Projected Subcontractor's Costs Other Than Monitoring *

$

Total Projected Subcontractor's Costs for Monitoring *

If value is entered above 0, you must select "Yes" to "Are subcontractors / vendors used?" in the next section.

$

Are any of the above part of wrap-up or OCIP projects?

Selecting "Yes" will reveal additional fields below.

Yes No

Do you monitor alarms?

Selecting "No" will reveal additional fields below.

Yes No

Describe your alarm response procedures: *

Subcontractors (Other Than Monitoring)

Yes No

Are subcontractors / vendors used?

Selecting "Yes" will reveal additional fields below.

Products Sold

Yes No

Are any products sold?

Selecting "Yes" will reveal additional fields below.

Client Percentages *

Client Base Breakdown

Client Category

% New Construction

% Rehab / Retrofit / Service

Row Totals

Apartments

% New Construction

%

% Rehab / Retrofit

%

0%

Commercial

% New Construction

%

% Rehab / Retrofit

%

0%

Condos

% New Construction

%

% Rehab / Retrofit

%

0%

Custom Houses

% New Construction

%

% Rehab / Retrofit

%

0%

Industrial

% New Construction

%

% Rehab / Retrofit

%

0%

Institutional

% New Construction

%

% Rehab / Retrofit

%

0%

Single Family

% New Construction

%

% Rehab / Retrofit

%

0%

Track Housing

% New Construction

%

% Rehab / Retrofit

%

0%

Work for Builder (Condos, Homes, etc.)

% New Construction

%

% Rehab / Retrofit

%

0%

Subtotals

New Construction

0%

Rehab / Retrofit

0%

Grand Total

0%

Gross Receipts

Operational Breakdown (Gross Receipts)

Operation

$ Sales / Install / Svc

$ Monitoring

Row Totals

Burglary (Perimeter / Internal / Motion)

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Carbon Monoxide Detection

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Central Vacuum

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Closed Circuit TV

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Fire / Smoke / Heat Detection

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Home Theater

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Intercom

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Medical Emergency Pendants

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Medication Reminder Service

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Personal Emergency / Panic Button

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Preconstruction Wiring / Conduit

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Temperature Control

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Utility Monitors (HVAC / Water / Gas)

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Water Flow on Sprinkler System

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Other

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Other

$ Sales / Install / Svc

$

$ Monitoring

$

$0

Subtotals

Sales / Install / Svc

$0

Monitoring

$0

Grand Total

$0

Desired Terms for Quote

Current Insurance Information

Yes No

Any claims in the last five years?

Selecting "Yes" will reveal additional fields below.

Yes No

Do you currently have insurance?

Selecting "Yes" will reveal additional fields below.

Licensed Agent / Broker Information

Yes No

Are you a licensed insurance agent or broker?

Selecting "Yes" will reveal additional fields below.

Comments & Priority

Comments or Additional Info:

Maximum 200 characters

Please Prioritize Your Request:

Hurry! I need it ASAP!

Please quote prior to my renewal

No hurry, just checking

Declarations and Legal Notices

Terms of Use & Declaration:

By submitting this quick quote application, you declare that:

the information you are providing is accurate and complete to the best of your knowledge and belief
you have read and agree to our underwriting conditions
you have read and agree to our Fraudulent Acts Notice
you have read and agree to our California Notice (CA businesses only)
you have reviewed and confirm as true, correct and complete each of the representations and warranties and all other information set forth in the application.

AMIS/Alliance Marketing & Insurance Services does not warrant or guarantee suitability or adequacy of coverage in meeting any generic, specific or contractual requirements of any insurance company, state, county, corporation, public entity, or public party that you may provide services to during the policy period, including any written or oral request forwarded to AMIS or its staff. You assume the risk of obtaining suitable or adequate coverage to meet any generic, specific or contractual requirements of your client or company. The information contained herein is provided with the understanding the AMIS is not engaged in rendering legal services, including legal opinions or advice, or professional risk management consulting. If legal services or professional services are required, you will need to seek the advice of legal counsel.

NOTE: An application or information form is not an insurance policy and does not bind any coverage. All applications must be underwritten and a quotation will be issued subject to underwriting guidelines. The quotation does not bind coverage.

Do you agree to the above? *

This constitutes your digital signature.

Yes No

Insurance Quick Quote

Alarms Systems & Installation, Burglary Alarms, Electronic Security, and Safety Equipment

Pre-Employment Screening Procedure (check all applicable)

Training Program Consists Of (check all applicable)

Percentage of Operations *

Payroll & Receipts Breakdown

Product Breakdown

Hand-Held / Portable Extinguishing Equipment Details

Client Base Breakdown

Operational Breakdown (Gross Receipts)

Current Insurance Details

Producer Information