Applicant Information

Existing SCD Members – please provide Member ID #
(front of SCD membership card)

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Cell Phone

Email *

Gender * MaleFemale

Date of Birth (MM/DD/YYYY) *

Second Call Defense pioneered the “Rapid Response” concept, offering legal and financial protection IMMEDIATELY after you use a gun in self defense. Our process depends on having key information at the ready when you call. In addition to the basic name and address information which you have already provided, we ask that you answer the questions below. We will regard this information as private and keep it securely on file for use in the event you call us in an emergency.

Memberships *
Please check all that apply

NRA

Second Amendment Foundation

Gun Owners of America

State Organization

Local Gun Club or Range

Other

Legal Background *
Have you ever been the subject of a lawsuit, criminal investigation, civil proceeding, or other legal action due to the use of a firearm?

YesNo

Permits and Licenses *
Second Call Defense and our members must abide by the federal, state, and local laws in each state. Please check all that apply to you in your primary state of residence. Or check "N/A" if none are applicable in your state.

Registration Requirement

Secure Store Requirement

Permit/License to Own or Possess

Permit/License to Transfer

Permit/License to Purchase

Out of State Concealed Carry Permit/License

Resident Concealed Carry Permit/License

N/A

Firearm Storage *
Please check all that apply:

Home Safe

Vehicle Safe

No dedicated storage facility in place

Other

Training *
We recommend that you keep a file with a record of any firearm, safety, or self defense training you have received. Please check all that apply:

Basic Gun Safety

Concealed Carry Class

Self Defense In The Home

Law Enforcement or Military Experience

Firearm Competition

None Taken

Advanced or Other Training

Emergency Contacts
In an emergency, we may need to contact family members or friends about your situation.
Please list one or two people we may contact:

Recruiter Information
If you were referred by a Second Call Defense Recruiter, please provide Name and ID#

Recruiter Name

Recruiter ID #

THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE. 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.

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

Membership Application