Return Applications To:
Public Servants Defense Agency
3001 Philadelphia Pike
Claymont, DE 19703
Tel: 888-304-1201 • Fax: 302-765-6037
 
NOTICE: THIS IS A CLAIMS-MADE FORM: EXCEPT TO SUCH EXTENT AS MAY OTHERWISE BE PROVIDED HEREIN, THE COVERAGE OF THIS POLICY IS LIMITED TO LIABILITY FOR ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED AND REPORTED IN WRITING TO THE COMPANY WHILE THE POLICY IS IN FULL FORCE. PLEASE REVIEW THE POLICY CAREFULLY. COVERAGE IS WRITTEN ON A SURPLUS LINES BASIS THROUGH CERTAIN UNDERWRITERS AT LLOYDS, LONDON
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PLEASE SELECT DESIRED LIMIT OF LIABILITY

* SELECT LIMIT OF
LIABILITY
TOTAL
AMOUNT DUE*
$100,000$250.00
$250,000$300.00
*Rates shown include all applicable premiums, taxes, and fees.

Member Information
* First Name:   Middle Initial: 
* Last Name:  
* Street Address:  
* City:   * State:   * Zip:  
* Phone:     Fax  
* Email:     
* Date of Birth:   * Gender:    
* Preferred Correspondence Method: 
* How did you hear about us?: 
       
* How long (in years) were you employed as a law enforcement officer?    
* For which agency/police department did you work?
 
* What was the date of your retirement?
 
* Please provide a brief description of your former duties/responsibilities:
 
* Are you currently employed?
 
If 'Yes', who is your employer?
 
If currently employed, please provide a brief description of your current job:
 
* Are you required to carry a firearm as part of your current duties?
 
* Have you been the subject of a lawsuit, criminal investigation, civil proceeding, or administrative action during the last 5 years?
 
If 'Yes', please provide details:
 


* 
THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE.  THE APPLICANT FURTHER WARRANTS THAT HE/SHE POSSESSES EITHER:
  • PHOTOGRAPHIC ID ISSUED BY THEIR PREVIOUS AGENCY THAT THEYHAVE, IN THE PREVIOUS 12 MONTHS, BEEN TESTED OR OTHERWISE FOUND BY THE AGENCY TO MEET THE ACTIVE DUTY STANDARDS FOR QUALIFICATION IN FIREARMS TRAINING AS ESTABLISHED BY THE AGENCY TO CARRY A FIREARM OF THE SAME TYPE AS THE CONCEALED FIREARM, OR
  • BOTH OF: –PHOTOGRAPHIC ID ISSUED BY THEIR PREVIOUS AGENCY, AND –A CERTIFICATION ISSUED BY THE STATE IN WHICH THEY LIVE, OR BY A CERTIFIED FIREARMS INSTRUCTOR (QUALIFIED TO CONDUCT A FIREARMS QUALIFICATION TEST FOR ACTIVE DUTY OFFICERS WITHIN THAT STATE) THAT INDICATES THAT THEY HAVE, IN THE PREVIOUS 12 MONTHS, BEEN TESTED OR OTHERWISE FOUND BY THE STATE (OR A CERTIFIED FIREARMS INSTRUCTOR) TO HAVE MET EITHER:
    • THE ACTIVE DUTY STANDARDS FOR QUALIFICATION IN FIREARMS TRAINING, AS ESTABLISHED BY THE STATE, TO CARRY A FIREARM OF THE SAME TYPE AS THE CONCEALED FIREARM; OR
    • IF THE STATE HAS NOT ESTABLISHED SUCH STANDARDS, STANDARDS SET BY ANY LAW ENFORCEMENT AGENCY WITHIN THAT STATE TO CARRY A FIREARM OF THE SAME TYPE AS THE CONCEALED FIREARM.
THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY.  SUCH POLICY MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE POLICY WAS OBTAINED THROUGH A FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF THE FACTS MATERIAL TO THE ACCEPTANCE OF THE RISK OR HAZARD ASSUMED.