JANITORIAL PROGRAM SUPPLEMENTAL 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:

Complete this application in addition to the General Liability Application

 1. How long have you been in business?      Currently: Full-Time    Part-Time
 2. Mix of business: Commercial %      Industrial %     Residential %

 3. Property Damage Extension (Occurrence/Aggregate)
 $5,000 / $25,000 $50,000 / $50,000
$10,000 / $25,000 $100,000 / $100,000
$25,000 / $25,000 $250,000 / $250,000

4.
Employee Data        
Number
Annual Payroll
Owner(s) only
$
Full-time (excluding clerical)
$
Part-time (excluding clerical)
$
Leased or Subcontracted
Number
Annual Cost
Leased Employees
$
Independent Contractors
$
 Do Independent Contractors provide you with Certificates of Insurance? Yes   No

 5. Indicate annual sales for each of the following industries serviced:
Operations for
Annual Sales
Operations for
Annual Sales
Aircraft $ Offices $
Apartments $ Off-shore oil rigs $
Construction Make-Ready $ Private Residences $
Convenience Stores, Grocery Stores
and Supermarkets		 $ Retail Stores $
Convention Halls $ Schools/Colleges/Universities $
Crime Scene Cleanup $ Shopping Centers & Malls $
Department Stores $ Sports Complexes $
Hospitals/Convalescent Homes $ Transportation Terminals $
Hotels $ Theaters $
Industrial $    
Other (describe)   $
Total Annual Sales   
 $

 6. Type of Operations Performed: (Show sales figures for bolded operations)
Operation
Payroll/Sales
Operation
Payroll/Sales
Carpentry $ Machinery/Equip. clean/degreasing $
Carpet/Upholstery Cleaning $ Painting $
Construction Cleanup Interior  Exterior $ Pressure Washing $
Consulting $ Recycling $
Equipment Rental $ Sandblasting $
Floor Stripping/Waxing $ Security $
Janitorial - General Services $ Snowplowing $
Janitorial Supply Retail/Wholesale $ Restaurant Hood Cleaning $
Landscaping/plant or shrub servicing $ Window/Screen/Skylight Cleaning $
Other (describe)   $

 7. Window Cleaning: Max. no. of stories     Scaffolding/rigging, if any: Rented   Owned

8. Please provide a brief description of any hazardous waste handled, storage of combustible material, and recyclables handled:   
 9. Are your employees bonded? Yes  No    If yes, effective date of coverage:

 Application Completed By:     Date: