LANDSCAPING GENERAL LIABILITY

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
                           Limited Liability Company 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) $  
  Property Damage Extension (CCC)

Occurrence  

 $
Aggregate  
 $
  Other $  
  Other $  
  Deductible ($500 minimum) $
 

LOCATION OF OPERATIONS
Street Address and City State
 1.   Same as mailing address
 2.

 3.

    
1. How long has applicant been in business?  years       Full-time       Part-time        
2. Does applicant use pesticides or herbicides?       Yes      No
     If yes, are they EPA approved       Yes       No
     How are employees trained in handling:
3. Does applicant subcontract work?      Yes      No
     If yes: Annual subcontract cost: $
     Type of work subcontracted:
     Are Certificates of Insurance obtained?       Yes      No
DESCRIPTION OF OPERATIONS

Operation

 Payroll

 Receipts
Landscaping

$

$

Lawn Servicing (mowing, fertilizing, etc.)

$

$

Snowplowing
Residential
 
Commercial - Retail
 
Commercial - Other
 
Streets and roads

$

$

$

$

$

$

$

$

Tree work

  

$

$

Fumigation, crop dusting or aerial spraying

$

$

Highway or utility right-of-way maintenance

$

$

Sales of commercial fruit trees and/or seeds

Not Applicable

$

Other - Please describe

  

$

$

Total Payroll (excluding snowplowing) 

$

$

EMPLOYEE DATA
Category

 Number

   During the past three years has any company ever canceled, declined or refused to issue similar insurance to the applicant?  (Not applicable in Missouri)
 Yes    No

If yes, please explain:


Owner(s) only

  Other than clerical:

  Full-time
  Part-time
  Leased

Total  
   
PRIOR INSURANCE HISTORY     See loss run attached

Year

Company

Policy No.

Premium

Paid Losses

Reserved Losses

Loss Description

ADDITIONAL INSURED INFORMATION
Name
Address
  
  
  

 Person Completing Application    Date
 Owner or Officer of Corporation    Title