Lloyds of London Pre-Risk Survey

Hiscox at Lloyd's of London * Pre-Risk Survey Application * Active Shooter/Malicious Attack Insurance Programs
1. Name of Entity to be Insured:
2. Address and Zip Code of the Insured:
3. Website:
4. Type of Educational Entity:

K - 12 University Technical School Private Charter Other
5. Please Provide a full schedule of all Locations detailing Addresses and Zip Codes of Each Building by Location:
6. Total Number of Buildings by Location:
7. Total Number of Floors for each Building by Location:
8. How Many Square Feet For each Building by Location:
9. Total Number of enrollment / students for each Building by Location:
10. Total Number of Staff for each Building by Location:
11. Do you have an Employee Assistance Program (EAP); If yes, please provide a copy:

Yes No
12. Do you have a written Policy on Workplace Violence that is available to all employees?; If yes, please provide a copy.

Yes No
13. Do you have a Policies and Procedures Manual for your Onsite Security Team.

Yes No
14. Do you have Staffing and Scheduling details for Onsite Security Team.

Yes No
15. Do you have an Emergency Plan, Security/Crisis Plan or Active Shooter Plan? If yes, please provide a copy.

Yes No
16. To the best of your knowledge, has the Entity suffered any violent acts, threats, attacks or incidents at any of their locations during the last five years? If yes, please provide further details.
17. Please provide (Two) designated points of contact for future Correspondence.
(Contact 1) Name:
(Contact 1) Position / Title:
(Contact 1) Telephone Number:
(Contact 1) Email:
example@example.com
(Contact 2) Name:
(Contact 2) Position / Title:
(Contact 2) Telephone Number:
(Contact 2) Email:
THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF THE COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE.

ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF.

The undersigned certifies that he or she is an authorized representative of the applicant identified in "APPLICANT DETAILS” and certifies that reasonable inquiry has been made to obtain the answers to these questions. He or she certifies that the answers are true, correct and complete to the best of his/her knowledge and belief.
Applicant:
Title:
Applicant's Signature:

Clear
Date:

Month Day Year
Date
Agent/Broker Name:
Should be Empty:

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Hiscox at Lloyd's of London * Pre-Risk Survey Application * Active Shooter/Malicious Attack Insurance Programs