1. Applicant's Name:
Contact For Inspection or Audit:
2. Desired Effective Date:
3. What are the applicant's total gross receipts?:
Provide Breakdown of receipts in the following categories
(Percentages 0% - 100%):
General Pest: %
Lawn & Ornamental: %
Fumigation * %
Inspections - New: %
Inspections - Total: %
Transit Pollution: If desired, please advisenumber of vehicles
owned / operated by applicant:
If fumigation is included, describe fumigation process and * chemicals used
4. Who are applicant's customers?(Provide percentages)
Are warnings posted prior to work performed?
5. How many employees (excluding owners) are employed?
What Training is provided for new employees?
Are new employees supervised until training is complete?
6. Is owner active in business?
7. How long has applicant been in business?
Has there been any changes in ownership, name or business
operations in last three years?
If so, describe:
8. What is applicant's state license number?:
9. Does the applicant engage in retail sale of chemicals?:
Are chemicals sold and handled as received from the manufacturer?:
If not, what alterations are made prior to sale?:
What is total volume in retail sales?:
10. Describe procedures used by applicant to ensure subcontractors used are adequately insured and supply proof of insurance to applicant:
11. Does applicant engage in any business other than pest control?:
If yes, describe:
12. How long does applicant maintain records on worked performed?:
13. List chemicals normally used by applicant:
14. Describe precautions used by applicant to secure chemicals at their business address and at job locations:
Are premises controlled regarding customer access to chemical
Are chemicals stored in manufacturers containers in separate
If so, please describe building:
15. Provide any past loss history, including date of occurrence, status of claim, and amount paid or current reserve:
16. Provide any further information you can to assist the company in underwriting your application:
17. Prior insurance carrier:
Person Filling Application: