Section I. Applicant InformationFirst Name*Last Name*Email* Phone*Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Title/Rank*Years on the force:*Full or Part Time Officer*Full or Part Time OfficerFull TimePart TimeAmount of on duty hours worked per week:*Amount of moonlighting hours worked per week:*Member for SWAT or a Task Force*YesNoSection II. Department InformationDepartment*Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Division*Section III. Incident DisclosureHave you ever used deadly force or been present during a deadly use of force incident?*YesNoHave you ever been involved in civil litigation/actions?*YesNoHave you ever been subject to an internal affairs investigation?*YesNoHave you ever been under review for a use of force incident?*YesNoHave you ever been demoted in the last five years?*YesNoHave you ever been terminated from law enforcement?*YesNoHave any claims been brought against you as an individual police officer in the last five years?*YesNoIf any of the answers to the questions above are “yes”, please attach documentation and an explanation for each such incident.* Drop files here or Accepted file types: pdf, pages, docx, doc. Liability Coverage*$100,000$250,000$500,000Individual Attestation The authorized signer of this application attests to the best of his/her knowledge that statement set forth herein are true; that no fact, circumstances or situation indicating the probability of a claim or action now known or has not been declared; and it is agreed by all concerned that omission of such information shall exclude any such claim or signing of this application does not bind the signer to purchase the insurance, but is agreed this form shall be the basis of the contract should a policy be issued, and this form will serve as the basis of and will be referenced in the policy. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.Applicant Signature*Today's Date* Date Format: MM slash DD slash YYYY
