Police Protective Liability Insurance Form

Qualify and Purchase Insurance

JMG’s police protective liability insurance policies help by offering law enforcement officials a sense of ease. By offering three coverage options we are able to meet varying needs. Below are the pricing that applies for each.

Plans requiring $100,000 in coverage: $479
Plans requiring $250,000 in coverage: $935
Plans requiring $500,000 in coverage: $1,612

At JMG, we care for the safety and mental well-being of our police officers. Seek out our police liability insurance coverage, and stay safe while on the job! Fill out our short application form to qualify and purchase insurance today.

Once you submit your answers and if you qualify you will automatically be redirected to the payment page. Here you can put in your payment information to purchase coverage. Once this is done, your coverage goes into effect immediately.

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Title/Rank(Required)

Years on the force:(Required)

Full or Part Time Officer(Required)

Amount of on duty hours worked per week:(Required)

Amount of moonlighting hours worked per week:(Required)

Member for SWAT or a Task Force(Required)

Yes

Section II. Department Information

Department(Required)

Department Address(Required)

Street Address Address Line 2 City State ZIP Code

County(Required)

Division(Required)

Section III. Incident Disclosure

Have you ever used deadly force or been present during a deadly use of force incident?(Required)

Yes

Have you ever been involved in civil litigation/actions?(Required)

Yes

Have you ever been subject to an internal affairs investigation?(Required)

Yes

Have you ever been under review for a use of force incident?(Required)

Yes

Have you ever been demoted in the last five years?(Required)

Yes

Have you ever been terminated from law enforcement?(Required)

Yes

Have any claims been brought against you as an individual police officer in the last five years?(Required)

Yes

If any of the answers to the questions above are “yes”, please attach documentation and an explanation for each such incident.(Required)

Drop files here or

Accepted file types: pdf, pages, docx, doc, Max. file size: 100 MB, Max. files: 5.

Requested Liability Coverage Limit(Required)

$100,000

$250,000

$500,000

Individual 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(Required)

Today's Date(Required)

Qualify and Purchase Insurance

Section II. Department Information

Section III. Incident Disclosure

Individual Attestation

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