Insurance Quick Quote

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

FOR MORE INFORMATION ABOUT THIS INSURANCE PROGRAM, CLICK HERE

First Name:	Middle Initial: Last Name:
Business Name:

Do you operate from a residence?	Yes No
	THE BUSINESS ADDRESS MUST BE A STREET ADDRESS - NOT A PO BOX.
Business Address:
City:	State: Zip Code:
	If both addresses are the SAME, please leave MAILING Address BLANK.
Mailing Address:
City:	State: Zip Code:

Email Address:

Business Phone:	- -	Home Phone:	- -
Mobile Phone:	- -	Fax Number:	- -

Information About Your Business

State License Number and Type:

Corporation	Partnership	Limited Liability Corp (LLC)
Individual	Other - Explain:

Date Business was Established:

Years of Experience:

Brief Details of Experience:

List the names of your five largest clients and describe your duties for them:

Do you have a brochure?

Yes No

Do you use a written contract?

Yes No

Annual Contract Cost: $
Percent of Customers Under Standard Contract:	%

Do you or your agency belong to any associations?	Yes No

Association Name(s):

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

Describe Other Training:

Operations

	% Alarms	% Safety	% Other
Total must equal 100%

Describe Other Operations:

Owner's Duties:
Do you work at facilities where explosives are handled or stored or at nuclear power plants?	Yes No

If yes, please describe:

Do you do any design work?	Yes No

If yes, please describe:

Do you install or service safety equipment in nursing homes, medical, correctional, or detention facilities?	Yes No
Do you install safety equipment in buildings over four (4) stories?	Yes No
Are you covered under a Broad Form Vendors endorsement by manufacturers?	Yes No

Payroll / Receipts

	Installation	Manufacturing	Sales / Distribution	Service	Other
Payroll $
Receipts $

Describe 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:	$
Are any of the above part of wrap-up or OCIP projects?	Yes No

If yes, please describe:

Do you monitor alarms?	Yes No

If no, list the name(s) of your monitoring subcontractor(s):
Do you have a written contract with your monitoring subcontractor(s)?	Yes No

Describe your alarm response procedures:

Subcontractors (Other Than Monitoring)

Are subcontractors / vendors used?	Yes No

Number Used:
Annual Amount Paid: $
Type of License (if required):
Are they licensed in the state in which they operate?	Yes No

If yes, what state?

Do you have a written contract with all your subcontractors?	Yes No
Do you obtain Certificates of Insurance from all your subcontractors?	Yes No
Are you always added as an additional insured by your subcontractors?	Yes No

If no, what percent of subcontractors add you as an additional insured?	%

Contractually required minimum limit of liability insurance:	$
Type of Work Subcontracted:

Products Sold

Are any products sold?	Yes No

	% Hand-Held Extinguishers	% Personal / Safety First Aid	% Other
Total must equal 100%

Describe other products that you sell or handle (protective clothing, life support, etc.):

Identify Manufacturers:	(255 characters)

Hand-Held / Portable Extinguishing Equipment - Installation, Sales or Service

	% Computer Rooms	% Factories	% Restaurants	% Other
Total must equal 100%

Describe Other Locations:

Client Percentages

Client Base	% New Construction	% Rehab / Retrofit Service / Repair	Totals
Apartments
Commercial
Condos
Custom Houses
Industrial
Institutional
Single Family
Track Housing
Condos, Custom Homes, Single Family, Track Housing Work for Builder
Subtotals

Gross Receipts

Operation	$ Sales / Installation Service / Repair	$ Monitoring	Totals
Burglary (Perimeter / Internal / Motion Detector)
Carbon Monoxide Detection
Central Vacuum
Closed Circuit TV
Fire / Smoke / Heat Detection
Home Theater
Intercom
Medical Emergency Pendants
Medication Reminder Service
Personal Emergency / Panic Button
Preconstruction Wiring / Conduit
Temperature Control
Utility Monitors (HVAC / Water / Gas)
Water Flow on Sprinkler System
Other
Other
Subtotals

Limits of Liability / Coverage Information

Requested Effective Date for New Policy: / / (M / D / YYYY)

Limits of Liability:	$300,000	$500,000	$1,000,000/$2,000,000
	$1,000,000/$3,000,000	$2,000,000/$3,000,000	$3,000,000/$4,000,000
	$4,000,000/$5,000,000	$5,000,000	Other:

Deductible:	$500 Per Claim	$1000 Per Claim

Current Insurance Information

Any claims in the last five years?	Yes No NOTE: We will need loss runs prior to binding coverage.

If claims in the last five years - explain:

Do you currently have insurance?	Yes No

	If YES, please complete this section.
Prior or Current Insurance Company:		Policy Number:
Policy Limit: $		Premium Amount: $

Licensed Agent / Broker Information

Are you a licensed insurance agent or broker?	Yes No

	If YES, please complete this section.
Producer (Insurance Agent/Broker):
Insurance Agency Name:
Email Address:

Prior to binding any coverage with AMIS, we must have a signed Broker Agreement, a copy of your Broker/Insurance License, and a copy of the declaration page of your E & O Insurance policy. Click here for more information.
Did you previously provide your agency information to AMIS?	Yes No

	If NO, please complete this section.
Agency License Number:
Street Address:
City:	State: Zip Code:
Contact Person Phone:	- -
Name of E&O Insurance Company:
E&O Policy Number:
E&O Policy Expiration Date:	/ / (M / D / YYYY)

Comments, Priority, Terms of Use

Comments or Additional Info:
Please Prioritize Your Request:	Hurry! I need it ASAP! Please quote prior to my renewal No hurry, just checking

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 (Click here to view the conditions)
you have read and agree to our Fraudulent Acts Notice (Click here to view the notice)
you have read and agree to our California Notice (CA businesses only) (Click here to view the CA notice)
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.

Depending on the size of the risk, a full completed application may be required in order to receive a formal quotation prior to binding coverage. AMIS may elect to withdraw any indication quote upon review of a full completed application if the application does not meet the underwriting guidelines of the insurance company. Click here to view the underwriting conditions.

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.

You agree:	Yes NoNOTE: This constitutes a digital signature.

ATTENTION: You must click the Submit button to complete this request for a quote.
Please wait for an acknowledgement before closing your browser or window.

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.

Insurance Quick Quote

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

FOR MORE INFORMATION ABOUT THIS INSURANCE PROGRAM, CLICK HERE

Information About Your Business

Employment / Training

Pre-Employment Screening Procedure (check all applicable)

Training Program Consists Of (check all applicable)

Operations

Payroll / Receipts

Payroll / Subcontractor's Costs / Monitoring

Subcontractors (Other Than Monitoring)

Products Sold

Hand-Held / Portable Extinguishing Equipment - Installation, Sales or Service

Client Percentages

Gross Receipts

Limits of Liability / Coverage Information

Current Insurance Information

Licensed Agent / Broker Information

Comments, Priority, Terms of Use

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