| Company Name: |
CorpLLCPartnershipsole prop |
| Contact Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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| Website: |
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| Years Experience: |
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| Years In Business: |
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| Are you a member of any pest control association? |
NoYes |
| If so which one/s?: |
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| If in business less than 3 years, name and location of previous pest control employer: |
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| Effective Date: |
 |
| Federal Employer ID #: |
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| Current insurance Company name (not agent): |
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Estimated SALES BREAKDOWN
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Next 12 Months: |
| Wildlife Control (NO Dogs, cats, gators, crocs, Bears or Use of FIREARMS) |
$ |
| General Pest Control: |
$ |
| Termite Inspections: |
$ |
| Termite Control: |
$ |
| Lawn Care: |
$ |
| Mosquito: |
$ |
| Fumigation: |
$ |
| Other Operations: |
$ |
| TOTAL |
$ |
| Limits of Liability |
$1,000,000 occurence / $2,000,000 aggregate |
| Other Desired Limit: |
$ |
| Deductible |
$1000$500 |
| Any Claims in Past 3 Years? Explain..: |
No claims Yes, details |
| Umbrella limit? ($1MM- $50MM available): |
$ |
| 1)Does Applicant own or operate any other business? |
NoYes |
| 2) Is work done through or by any affiliated or related companies? |
NoYes |
| 3) Has Applicant or any affiliated, related or predecessor entity or any officer or owner of any of them ever been convicted of a crime? |
NoYes |
| 4) Has Applicant or any affiliated, related or predecessor entity ever defaulted on a labor and material payment bond, performance bond or bid bond or failed to complete or been terminated on any project? |
Noyes |
| 5) Has Applicant or any affiliated, related or predecessor entity currently involved in any litigation, administration, or arbitration proceeding(s) or subject to any court or agency order of injunction? |
noYes |
| 6) Has Applicant or any affiliated, related, or predecessor entity ever been cited by any governmental/regulatory agency or by civil court for violation of any regulations, safety, health, or product label, environmental laws or regulations? |
NOYes |
| 7) Do you have any knowledge of or reason to expect claims to be filed arising out of pest control operations prior to the effective date of coverage with this company? |
NoYes |
8) Does Applicant perform building inspections or appraisals, or issue or render services or opinions regarding structural integrity, chemical, air quality or health-related mold issues?
(THESE SERVICES, REPORTS, AND OPINIONS ARE NOT COVERED!) |
NoYes |
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| 9) Is pest control operation a full-time business for Applicant? |
NoYes |
| 10) Does Applicant perform any non-pest control services such as Janitorial, Carpentry, Excavation/Grading, Insulation, Roofing, Plumbing or General Construction? |
NoYes |
| 11) Are Subcontractors insured (if used)? |
NoYes |
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By acceptance of an insurance policy based on this application, the Insured and/or his representative agrees that the statements in this application are the Insured’s representations, that they shall be deemed material and that the insurance policy is issued in reliance upon the truth of such representations, and that the insurance policy embodies all agreements existing between the Insured and the Company, or any of its agents, relating to this insurance. The Insured acknowledges that this application is a part of the insurance policy.
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Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: Substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, or VT: in DC, LA, ME and VA, insurance benefits may also be denied).
By clicking Submit I agree to these conditions
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