Security Liability Insurance Questionnaire & Application

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Applicant Contact Details

Registered Name of Business

Trading Name (if applicable)

Company Registration Number

VAT Registration Number

Telephone Number*

Facsimile Number

Email Addres

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Description of Business Operation

Applicant's Employee Screening Details

Does the applicant subcontract work to others?

Yes

Description of functions

Are background investigations and checks conducted on employees?

Yes

If yes, please mark the appropriate box below that’s applicable:

Criminal Background Checks

Previous Employer

Personal References

Fingerprints

Drug Screening

Other

Are any watercraft used?

Yes

Number of watercraft

Description of watercraft

Are any cash-in-transit, armoured vehicles, etc. used?

Yes

Number of armoured vehicles

Description of armoured vehicles

Any alarm installation/repair or monitoring operations?

Yes

Describe alarm installation/repair or monitoring operations.

Do you have a Legal Commercial policy?

Yes

Include the number of employees per security service rendered.

Full-time Armed

Full Time Armed Guarding

Full Time Armed Reaction

Full Time Armed VIP Protection

Full-time Unamrned

Full Time Unarmed Guarding

Full Time Unarmed Armed Reaction

Full Time Unarmed VIP Protection

Company Financial Information

Gross Annual Turnover

Projected Turnover for the Next 12 Months

Annual Payroll for Employees (Excluding directors, partners, sole proprietors or administrative personnel.)

Please indicate the category of security services rendered:

Armed Reaction

Shoplifting

Residential Patrol

Airports

Surveillance

Restaurants

Alarm Response/Monitoring

Access Control

Fast Food Restaurants

Bodyguards/VIP**

Goods Dispatch

Schools

Undercover

Government Facilities

Shopping Mall Interior

Hospitals

Liquor Stores

Shopping Mall Parking Lots

Hotels/Motels

Manufacturing Plants

Warehouses

Guarding

Offices

Bars/Lounges

Consultancies

Training Centres

Car Dealerships

Banks

Construction Sites

Churches

Civil

Concerts

Retail Stores

Events

Armoured Car / Courier/Money Escort/CIT

Supply, Installation and Maintenance of Alarm systems

Please provide your annual turnover (Rand) for the items as listed below:

Armed Reaction Annual Turnover

Body guards / VIP Annual Turnover

Guarding Annual Turnover

Supply, Installation & Maintenance of Alarm Systems Annual Turnover

Does your business belong to any association and have a PSIRA?

Yes

Membership Number

Please describe your training procedures for security officers

Dogs

Number of dogs in the field

Are they leashed or free-roaming?

Where and how are they used? Please describe any drug or bomb-sniffing activities at airports or national key points.

Claims / Prior Insurance

Have any claims been made or suits brought against you during the past five years?

Yes

Explain any claims been made or suits brought against you during the past five years?

Are you aware of any circumstances that may be reasonably expected to result in a claim being made against your or any of your business predecessors, subsidiaries or affiliates or against any of the past or present directors, owners, staff or company?

Yes

Explain any circumstances that may be reasonably expected to result in a claim being made against your or any of your business predecessors, subsidiaries or affiliates or against any of the past or present directors, owners, staff or company?

Have you or any of your business predecessors, subsidiaries, affiliates, past or present directors, owners, officers, staff, or employees been investigated and/or cited by any regulatory authority for violations arising out of your activities?

Yes

Explain any of your business predecessors, subsidiaries, affiliates, past or present directors, owners, officers, staff, or employees been investigated and/or cited by any regulatory authority for violations arising out of your activities?

Who was your previous/current insurance company for the past three years?

Policy Number

Cover

Policy Start Date

Policy End Date

Limits of Liability / Cover Required

Annual Policy Limit

Inception Date of this Policy

Comments

Decleration

Full Names

Place

Date