Individual Application for Law Enforcement Officers

"*" indicates required fields

Step 1 of 5

GENERAL INFORMATION

Last Name*

First Name*

Middle Name*

Years Employed as a Law Enforcement Officer

Residence Address

Mobile Phone

Business Phone

Residence Phone

Email Address*

LAW ENFORCEMENT EMPLOYMENT HISTORY FOR THE LAST 10 YEARS

Current Department

Current Department Precinct OR correctional facility (if applicable)

Current Department Division (for example, patrol officer, ESU, Narcotics, etc)

Current Department Rank (if applicable)

Current Department Dates at location

Previous Department (if applicable)

Previous Department Precinct OR correctional facility (if applicable)

Previous Department Division (for example, patrol officer, ESU, Narcotics, etc)

Previous Department Rank (if applicable)

Previous Department Dates at location

CONTINUING EDUCATION AND TRAINING

What continuing education and training have your officers participated in within the last 5 years?
Please provide a curriculum description.

Education Training

PROFESSIONAL HISTORY

In the last 5 years have any officers experienced any disciplinary action? If yes, please provide details on allegation(s), date of incident(s), result of the investigation, and settlement OR judgment amount.

Professional History

Are you aware of any circumstances or incident which may result in any claim against you? If yes, provide full details.

Professional History Circumstances or Incident

COVERAGE OPTIONS

Limits of liability (choose one)

$25,000 per claim/ $25,000 aggregate

$50,000 per claim/ $100,000 aggregate

$100,000 per claim/$200,000 aggregate

$250,000 per claim/$500,000 aggregate

$500,000 per claim/$1,000,000 aggregate

Requested Coverage Period (12:01 am)

Date

Time

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