Contact Name First Name Last Name Company Name Contact Email * Website http:// Insured Address Physical location of entity. Address 1 Address 2 City State/Province Zip/Postal Code Country Number of Locations Approximate square footage If multiple, please differentiate between locations. Distance to the nearest police station or fire department Years in Business Number of Employees Includes full-time, part-time and contracted (1099) laborers. If multiple locations exist, please identify the number of employees at each location. Number of Volunteers Any staff who do not receive financial compensation. Number of total visitors/students/guests/etc. Check if there is currently: Check all that apply. An Employee Assistance Program (EAP) A progressive discipline policy An employee grievance/dispute resolution procedure A customer complaint/grievance resolution procedure A written policy on workplace violence that is available to all employees A program to train supervisory and management personnel to recognize, report and respond to all hostile employees or situations. A background check procedure for all potential employees Business Type Place of worship, retail property, concert venue, etc. Limits Please select which insurance limits you would like to be quoted for. 1,000,000 3,000,000 5,000,000 10,000,000 15,000,000 20,000,000 >20,000,000 Total annual business revenue Does the entity have: Please check all that apply. If you are unsure, please leave the option blank. An onsite security team An emergency plan that sets out response protocols An Active Shooter plan in place A security/crisis management plan in place Drills/exercises for employees Security screening measures for employees Email/social media monitoring Additional comments Please provide any additional details you feel may have been missed. Thank you!
