Polygraph Examiner Insurance Questionnaire

Polygraph Examiner Insurance Questionnaire
Applicant's Name
Address
Mailing Address
Address (cont.)
Mailing Address - continued
Contact Person*
Email:
Telephone:*
Website
Fax Number
Applicant is:

IndividualPartnershipCorporationOther
Do you currently carry liability insurance?

YesNo
Current Carrier
Policy Expiration Date
Limits
Premium
Deductible
GENERAL INFORMATION
(Private Investigator, Private Detective, Process Server, Insurance Claims Adjuster, Skip Tracing, Polygraph Testing, Undercover Surveillance, Detective/Security Instruction, Forensic, “Expert Witness” Testimony, Security Consulting, Firearms Training)

1. Do you perform any of the following services?

	Yes	No
Airport Services
Bodyguard (including executive protection)
Bounty Hunting
Casino Security
Work for Government Agencies
Fast Food
Restaurant
Tavern or Nightclub Security
Work for Banks
Repossession Work
Traffic Control

2. Please indicate what percentage of your operation consists of the following services:

	Percentage
Arson Investigation
Body Guard/Executive Protection
Collection Agency Services
Detective/Security Instruction
Drug Screens
Electronic Sweeps
“Expert Witness” Testimony
Labor Dispute Intermediaries
Polygraph Testing
Process Service
Residential/Habitational Surveillance
Schools
Security Consulting Work
Shoplifting Surveillance
Special Event Security
Skip Tracing
Undercover Surveillance
Workforce Infiltration
Firearms Instruction
Fingerprint Vendor Services
Other (Describe in 1a below)
Total (Must add up to 100%)

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2

	Payroll
Armed
Unarmed