
IMPORTANT NOTICE: Completion of this form is
necessary for consideration for licensure under 225 ILCS
446/1 et. seg. (Illinois Compiled Statutes). Disclosure of
this information is VOLUNTARY. However, failure to
comply may result in this form not being processed.
SUPPORTING DOCUMENT
DE-INS
CERTIFICATE OF INSURANCE
1. NAME OF INSURED (must be exactly as it appears on application,
renewal form of individual license.)
4. ADDRESS STREET, CITY, STATE, ZIP CODE (specific address
as noted on license)
6. MAIDEN OR GIVEN SURNAME
8. TELEPHONE NUMBER (where you can be reached during the day-
time)
Area Code ( ___ ___ ___ ) ___ ___ ___
_
___ ___ ___ ___
Under penalties of perjury, I declare that I have examined the policy and this completed form and to the best of my knowl-
edge, the statement is true, correct, and complete.
INSURANCE COMPANY/INSURANCE PRODUCER: Complete the following information and return the form to the applicant licensed
under the Private Detective, Private Alarm, Private Security, Fingerprint Vendor, and Locksmith Act.
A. NAME OF INSURANCE COMPANY
C. INSURANCE COMPANY HOME ADDRESS:
STREET, CITY, STATE, ZIP CODE
H. EFFECTIVE DATE OF POLICY
Signature of Applicant/Licensee Date
Signature of Agent Date
IL486-1280 1/13 (DE)
APPLICANT: Complete the applicant section of this form, then have your authorized insurance agent complete the
remainder of the form. The completed form must be submitted WITH your application for licensure or
renewal form. Insurance must be in the name of the individual license holder. The comprehensive,
commercial general liability insurance must be in the name of the individual licensee.
__ __ __ - __ __ - __ __ __ __
5. NEW APPLICANTS ONLY
REFER TO REFERENCE SHEET. Record profession name and three digit
profession code for which you are making Illinois application.
2. DATE OF BIRTH
Profession Name
7. RENEWAL APPLICANTS AND PERSONS VERIFYING CURRENT
INSURANCE ONLY -- Record each individual license number you hold
under the Private Detective, Private Alarm, Private Security, Fingerprint
Vendor, and Locksmith Act.
Profession Code
115 -
119 -
124 -
191 -
B. NAME OF AUTHORIZED AGENCY/PRODUCER
D. NAME AND ADDRESS OF AGENT'S BUSINESS: STREET, CITY,
STATE, ZIP CODE
I. EXPIRATION DATE OF POLICY
Area Code ( ___ ___ ___ ) ___ ___ ___
_
___ ___ ___ ___
E. INSURED'S POLICY NUMBER
G. AGENT'S BUSINESS TELEPHONE NUMBER
3. SOCIAL SECURITY NUMBER
Month Day Year
__ __ / __ __ / __ __ __ __
Month Day Year
__ __ / __ __ / __ __ __ __
Month Day Year
__ __ / __ __ / __ __ __ __
The comprehensive commercial general liability insurance policy, with proof of a minimum of $1,000,000 of liability insurance, must
include coverage for bodily injury liability, property damage and personal injury. If the licensee carries a firearm in the course of
duty, coverage must extend to claims for injury or damage resulting from the use of firearms while acting in the course of employ-
ment. Additionally, if the licensee serves as the licensee in charge of an agency, and the licensee in charge of that agency permits
anyone associated with it to carry a firearm, then coverage must extend to claims for injury or damage resulting from the
employee's use of firearms while acting in the course of employment. Under penalties of perjury, I declare that I am an autho-
rized agent of the above insurance company; I have examined the policy referenced above and this application, and to the best
of my knowledge, the policy meets the requirements and provides liability coverage for the licensee's operations in the State of
Illinois and statements made here are true, correct and complete. If this policy is terminated prior to expiration, the insurer
agrees to provide written notice to the Department of Financial and Professional Regulation thirty (30) days prior to cancellation.
F. TITLE OR TYPE OF POLICY