SPI On-Line Insurance Application – Yergey Insurance Services, LLC

Name of Applicant/Business Name (Name Insured) *

Complete name as it should appear on the policy including Inc., Corp., Ltd., LLC., Etc...
Business Entity Type *

Corporation Limited Liability Company Individual / Sole Proprietor Partnership
Contact Name *

First

Last

Main Contact
Email *

Business Contact Email
Physical Address *

Address Line 1 *

City *

State *

Zip Code *
Mailing Address (If Different)

Address Line 1

City

State

Zip Code
Business Phone Number *

Business Phone
Fax Number

Fax Number
Mobile Phone Number

Cell Phone Number
Federal ID Number

XX-XXXXXXXXX
Please list all Associations, Memberships and Certifications:
Associations and Groups

APAI FAPI IAAI INTELLENET LPDAM Madison - Contractor NAFI NAPPS NCAPI NCISS NFL NJLPIA PALI PIAVA PSACO SCALI WALI
Operations

Please provide the percentage of revenue from each type of operation below:
Accident Reconstruction

It is an area of investigation that utilizes engineering, physics, mathematics, photogrammetry, simulations, and computations to essentially reconstruct the accident to get a better idea of what happened.
Accounting Forensic / AML Investigations

Anti-money laundering (AML) refers to the contemporary web of laws, regulations, and procedures aimed at uncovering illicit funds disguised as legitimate income.
Arson / Property Investigations

Arson investigators play an essential role in examining fire scenes, collecting evidence and determining whether a fire's spread resulted from criminal activity.
Attorney / Legal Investigations

A legal investigator is a professional who researches and uncovers information relevant to a court case.
Background Investigations

A background investigator is a research specialist who verifies the personal information of individuals and sometimes gathers information about organizations.
Computer Forensic

Computer forensics is the application of investigation and analysis techniques to gather and preserve evidence from a particular computing device in a way that is suitable for presentation in a court of law.
Conservator of Peace (SCOP)

Any individuals who have been appointed by a Circuit Court to perform only those powers, functions, duties and responsibilities authorized within such geographic limitations as the court may deem appropriate.
Constable Services

Constables serve restraining orders, summons and subpoenas, court orders, service of process, writs and arrest warrants, and act as court bailiffs.
Consulting
Copyright / Trademark Investigations
Cyber Security Investigations
Debugging / TSCM
Executive Protection - Low Profile
Exiting Interview (Corporate)
Expert Witness Services
Fidelity Investigations / Domestic
Fingerprint Analysis
Firearms Training - Classroom Only
Firearms Training - Range
Genealogy Investigations
Insurance Investigations
Juvenile Investigations
Kidnap and Ramson
Lie Detection / Polygraph
Locate / SkipTrace
Mortgage/Court - Auction Services
Online Searches
OSINT Investigations

Open-Source Intelligence (OSINT) is defined as intelligence produced by collecting, evaluating and analyzing publicly available information with the purpose of answering a specific intelligence question.
Process Service / Subpoena

A process server is a career in the legal field. The primary job function of people in this role is to deliver and serve legal documents to people involved in court cases and other legal actions.
Security Training
Shopping Services/Mystery Shopping
Sub-Rosa Investigations
Threat/Vulnerability Assessment
Under Cover Investigations
Other Operations

Other operations that are not listed above.
Other - Please Descibe:
Rating Information
Your companies expected annual revenue: *

$0 to $150,000 $150,001 to $250,000 $250,001 to $350,000 $350,001 to $450,000 $450,001 to $550,000 $550,001 to $650,000 $650,001 to $750,000 $750,001 to $1,000,000 $1,000,001 to $1,250,000 $1,250,001 to $1,500,000 $1,500,001 to $1,750,000 $1,750,001 to $2,000,000 $2,000,001 and Above
Desired Limit of Liability: *

$300,000 / $600,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $5,000,000 $2,000,000 / $2,000,000 $3,000,000 / $3,000,000 $4,000,000 / $4,000,000 $5,000,000 / $5,000,000
Request Limit of Business Personal Property Coverage: (Furniture & Fixtures)

$25,000 - Included - NO COST $50,000 $100,000 Business personal property (BPP) insurance provides coverage for items that your business uses, rents or owns within your building — but not the building itself. BPP insurance can help cover the cost of repairs or replacement of damaged items, up to the limits of your policy.
Underwriting Section
Total number of Employees? (Inclusive of all investigators)
Number of Investigators?
Does the applicant subcontract any investigative work?

YES NO
If Yes - What percentage of work is subcontracted?
If Yes - Are subcontractors required to maintain their own liability coverage at a minimum limit of $300,000/$600,000?

YES NO
During the past five(5) years, has any claim been made or suit brought against the applicant? *

YES NO (If Yes, please provide details on a separate attachment.)
Is the Applicant aware of any circumstance, allegation, contention, or incident which may result in a claim or suit against the Applicant? *

YES NO (If Yes, please provide details on a separate attachment.)
Has any insurer canceled or refused to renew any similar insurance during the past five (5) years? *

YES NO (If Yes, please provide details on a separate attachment.)
Does any operation require you to carry and/or use of a firearm? *

YES NO (IF YOU CARRY FOR YOUR OWN PROTECTION, ANSWER NO)
Optional Coverage
DECLINE OPTION

NO Thank You GO TO NEXT SECTION
Hired and Non-Owned Auto

$300,000 $500,000 $1,000,000
Does the applicant have a commercial auto policy in place?

YES NO
Does the applicant rent or hire auto in excess of 10 times per year?

YES NO
Does the applicant use any auto to transport clients?

YES NO
Does the applicant own any auto registered in the company's name or leased on a long term basis?

YES NO
Waiver of Subrogation

TO INCLUDED - Additional Cost $150 A waiver of subrogation is a contractual provision whereby an insured waives the right of their insurance carrier to seek redress or seek compensation for losses from a negligent third party.
Primary Non-Contrubtory

TO INCLUDED - Additional Cost $150 This means that the contractor's policy must pay before other applicable policies (primary) and without seeking contribution from other policies that also claim to be primary (noncontributory).
Stop Gap Coverage (Ohio, North Dakota, Washington and Wyoming)

TO INCLUDED - Additional Cost Stop gap coverage provides a form of employers liability insurance for employers who do not have the coverage because they operate in a so-called monopolistic state.
Nose Coverage

TO INCLUDED - Additional Cost Transition from Claims Made policy to an Occurrence Form policy - One Year Additional Cost
Does the applicant or any principals, directors, officers, partners, professional employees, or independent contractors of the applicant have knowledge or information of any actual or alleged acts, errors, omissions, offenses, or circumstances which might reasonably be expected to give rise to a claim against the applicant or any proposed insured entity?

YES NO
Worldwide Coverage

TO INCLUDED - Additional Cost
Other Coverage

Quote Request
Other Coverages

Cyber/Privacy/Crime Coverage Surety / License Bonds Inland Marine Coverage Workers Compensation Commercial Auto Directors and Officers Liability (D&O) Employee Practice Liability (EPLI) Drone / Unmanned Aircraft Liability
Applicant's Warranty Statement

The undersigned represents to the best of his/her/they/them knowledge and belief the particulars and statements set forth are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw or modify and any outstanding quotations and/or authorization or agreement to bind the insurance. The signing of the Application does not bind the undersigned to purchase the insurance, nor does the review of the Application bind the Company to issue a policy. It is understood the Company is relying on the Application in the event the Policy is issued. It is agreed that this Application, including any material submitted therewith, shall be the basis of the contract should a policy be issued, and may be attached dot and become part of the policy.
Coverages

Coverage is not effective until approved by our underwriters and you receive our written conformation coverage is bound with your effective date and policy number is if you qualify, your effective date will be the date of your expiring policy subject to our receiving this request prior to the expiration date of that policy or if this is the first time you have purchased coverage, the date we approve your application.
Questions can be answered by calling Yergey Insurance at (800) 683-1226 or fax to (877) 418-5422
How did you hear about us?

Friend Association Ad or Flyer Conference Web Search
Individual Submitted the Application *

First

Last
Date / Time *

Operations

Rating Information

Underwriting Section

Optional Coverage

Other Coverage

Applicant's Warranty Statement

Coverages

Questions can be answered by calling Yergey Insurance at (800) 683-1226 or fax to (877) 418-5422