SPI Renewal 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 PAWLI 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

A trademark investigation involves research and discreet contact with sources to uncover information about the usage, non-use, abandonment or scope of use of a trademark.
Cyber Security Investigations

Cybersecurity investigations involve the systematic process of collecting, analyzing, and preserving digital evidence to uncover what happened during a cybercrime or security breach
Debugging / TSCM

SCM encompasses all countermeasures used to prevent or detect the interception of sensitive, classified, or private information.
Executive Protection - Low Profile
Exiting Interview (Corporate)
Expert Witness Services

An expert witness is a person whose opinion by virtue of education, training, certification, skills or experience, is accepted by the judge as an expert
Fidelity Investigations / Domestic

Fidelity investigations involve examining cases of employee theft or fraud within organizations. These investigations focus on uncovering instances where employees or third parties intentionally steal property, money, or securities.
Fingerprint Analysis

Fingerprint analysis is a forensic science technique used to identify individuals by their unique fingerprint patterns
Firearms Training - Classroom Only
Firearms Training - Range
Genealogy Investigations

Genealogy is the study of families, family history, and the tracing of their lineages. Genealogists use oral interviews, historical records, genetic analysis, and other records to obtain information
Insurance Investigations

An insurance investigator is an individual who inspects and researches an insurance claim to ensure no fraud is occurring
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
Underwriting Section
Does the applicant subcontract any investigative work? *

YES NO
If Yes - What percentage of work is subcontracted?
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
Individual Submitted the Application *

First

Last
Date / Time *

Operations

Rating Information

Underwriting Section

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