Waters Insurance Network

First Name

Last Name

Badge #:

County & State:

Email:

Title\Rank:

Years on Force:

Full or Part Time

Full Time

Part Time

Number of Duty Hours Worked per Week:

Number of Moonlighting Hours Worked per Week:

Member of SWAT or a Task Force?

Yes

No

Department Name:

Department Address:

Department Division:

FOP #:

Free Text

Incident Disclosure Section

Have you ever used deadly force?

Yes

No

Have you ever been present during a deadly use of force incident?

Yes

No

Have you ever been involved in civil litigation/actions?

Yes

No

Have you ever been subject to an internal affairs investigation?

Yes

No

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

Yes

No

Have you ever been demoted in the last 5 years?

Yes

No

Have you ever been terminated from law enforcement?

Yes

No

Have any claims been brought against you, as an individual police officer, in the last 5 years?

Yes

No

Please provide an explanation for each & every “yes” you selected in the Incident Disclosure section.

Do you have an attorney you would like to use to represent you in the event of an incident?*

Yes

No

If so, Please provide the attorney's contact details: Name, Address, Email Address & Phone number.

Free Text

*The company reserves the right to appoint their own attorney to represent you if not in agreement with your recommendation.

Section 1: Liability - Please select limit for coverage:

$100,000

$250,000

$500,000

Section 2: Death in the line of duty - please enter Name , Email & Phone Number of Designated Beneficiary(ies).

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Section 3

Monthly Salary:

Get in touch

+1 (508) 656-1480

Law Enforcement Liability Application

Law Enforcement Liability Application