Active Shooter/Workplace Violence Insurance Programs

Active Shooter/Workplace Violence Insurance Programs
1. Name of U.S. Entity to be insured:
2. Address and Zip Code of the Insured:
3. Website:
4. Years in Business:
5. Total Number of Locations:
6. Total # of Employees:
7. Total # of DAILY visitors / students / patients / etc:
8. Number of Employees at each location:
9. Does the Applicant have:
An Employee Assistance Program (EAP)?

Yes No
A progressive discipline policy?

Yes No
An employee grievance/dispute resolution procedure?

Yes No
A customer complaint/grievance resolution procedure?

Yes No
A written policy on workplace violence that is available to all employees?

Yes No
A program to train supervisory and management personnel to recognize, report, and respond to all potentially hostile employees or situations?

Yes No
What security measures limiting and/or monitoring public accesses are in place at Applicant locations?
10. Type of Entity (i.e. Government buildings, Retail property, House of worship etc)
11. Please select the limit options you would like quotes for:

$1,000,000 $3,000,000 $5,000,000 $10,000,000 $15,000,000 $20,000,000
12. What is the total annual revenue of the entity?
13. Provide full schedule of all Locations detailing (if more than one location please attach a schedule) the information below:
Address and Zip Code of Each Location:
Number of Employees at each Location:
Approximate size / number of visitors, students, patients, residents, etc:
Approximate Square FT of each location:
Distance to nearest police station or fire department:
14. Does the U.S. Entity have an onsite security team?

Yes No
If yes, please provide further details.
15. Does the U.S. Entity have an emergency plan that sets out response protocols, including evacuation, lockdown, accountability and reunification?

Yes No
If yes, please provide further details.
16. Does the U.S. Entity have an Active Shooter security plan in place? Are there any physical measures, or otherwise, in place to deter an attack or assault?

Yes No
If yes, please provide further details.
17. Does the U.S. Entity have a security / crisis management plan in place and are drills or exercises conducted?

Yes No
If yes, please provide further details.
18. Furthermore, have your security / crisis management plans been designed/ reviewed by an independent Risk Analysis Company?

Yes No
If yes, please provide further details.
19. Does the U.S. Entity have security screening measures in place for employees?

Yes No
If yes, please provide further details.
20. Does the U.S. Entity monitor email and social media?

Yes No
If yes, please provide further details.
21. What is the current budget for emergency preparedness (security personnel, equipment, emergency supplies, training/drills, notification/communication, and planning)?
22. To the best of their knowledge, has the U.S. Entity suffered any violent acts, threats, attacks or incidents at any of their locations during the last five years?

Yes No
If yes, please provide further details.
23. Please provide designated point of contact for future Event Responder contact / correspondence.
Name:
Position / Title:
Telephone Number:
Email:
example@example.com
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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