EXTERMINATORS GENERAL LIABILITY APPLICATION

Applicant's Name:
Mailing Address:
City    State        Zip
Phone:      Fax:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:
 Applicant is:   Individual Corporation Partnership Joint Venture
                            Other (Specify)

LIMITS OF LIABILITY REQUESTED
  General Aggregate $  
  Products & Completed Operations Aggregate $  
  Personal & Advertising Injury $  
  Each Occurrence $  
  Fire Damage (any one fire) $  
  Medical Expense (any one person) $ Excluded
  Other Coverages, Restrictions and/or Endorsements
Deductible  
 
 
$

 A. Is applicant licensed? Yes     No    License number      Years in Business

 B. Estimated annual sales  $

 C. Sales from termite inspections without termite treatment $ (this category does not include sales for renewal
     inspections where a previous treatment for termites had been done). Sales from termite treatment $

 D. Number of employees   Does applicant have a training program for his employees? Yes     No   
      If so, describe:
      

 E. Does applicant have Workers' Compensation coverage in force? Yes     No 

 F. Does applicant lease employees? Yes     No

 G. Does applicant do any tenting?  Yes     No    What percentage of sales? %

H. Describe operations of applicant (show percentage of sales for each)
     1. Exterminating - residential Yes     No   %
     2. Exterminating - commercial Yes     No %
     3. Crop dusting or spraying Yes     No  %
     4. Fumigation -residential Yes     No  %
     5. Fumigation - commercial Yes     No  %

 I. Does applicant do any random testing? Yes   No    If so, sales  Who does the analysis?

 J. Does risk store petroleum products in underground tanks, L.P.G., flammable liquids, ammunition or explosives on the premises?
   Yes   No   If so, type and quantity stored

 K. Does risk lend, lease, or rent any equipment to others? Yes   No
      If so, state the type of equipment involved and the sales derived therefrom.

 L. Does applicant subcontract work?   Yes   No   If so, state type

 M. During the past three years has any company ever cancelled, declined or refused to issue similar insurance to the applicant?
      Yes   No    If so, explain

 
Previous Insurance: Indicate premium and losses for past three years. Describe all losses.
Year
Company
Policy #
Premium
Pd Losses
Res Losses
Description

 

SCHEDULE OF HAZARDS
Loc. No.
Classification
Class.
Code
Premium Bases:
(a) Gross Sales
(p) Payroll (a) Area
(c) Total Cost (t) Other
Terr

 Application Completed By:     Date:
 Name and Phone Number of Individual to contact for Inspection/Audit: