ALARM APPLICATION
Complete form and Submit online or Download the Adobe Acrobat version and fax to 206.378.1136

Company:
DBA:
Address:
Policy #:
Expiration Date:
NBFAA #:
Contact:
Email:
Web Address:
Phone:
Fax:
Are you associated with a dealer program?

If yes, which one?

# of Employees:
Do you offer employee benefits?
OPERATIONS - Please indicate the % of gross sales/receipts by type of operation (total of all services should equal 100%)
Security/Fire Alarm Installation %
Security/Fire Alarm Service/Maintenance %
Monitoring, Non-Medical %
Medical Monitoring %
Security and Patrol Services, Armed %
Security and Patrol Services, Unarmed %
Locksmiths %
Fire Sprinkler Installation/Repair %
Hood/Vent Systems Installation/Repair %
Fire Extinguisher Installation/Service %
PERS Installation/Monitoring %
Other (Explain Below) %

Do you install, service, or monitor fire suppression systems?
Do you employees respond to site of alarm?
If yes, % of Contracts:
Have you added a showroom?
Describe all activities in detail:
List names of all operating companies and a description of those operations (include separate sheet if necessary):
Have you acquired any subsidiaries?
If yes, please describe on separate sheet:
REVENUE/CONTRACTS
   
Payroll-Total
Gross Sales
Suncontract Costs
Upcoming year
 
$
$
$
If you monitor for others, are you named as additional insured on all subcontractor polices?
What limits of liability do you require your subs to carry? $
Do you require subcontractors to sign a written contract that has an indemnity agreement holding you harmless?
Do you contracts include a limitation of liability/liquidated damages clause?
What is the dollar amount of your standard limitation? $
Are you aware of any occurrence or incident that may give rise to a claim?

If yes, explain:

       
       
Name:
Position:
     
 
Date:
       
       

 

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