Exterminator Liability Application
Instructions: This entire application must be completed. Read all questions carefully and provide complete answers. Fail-ure to provide complete information will result in delay in consideration of this application. This application is NOT an insurance policy and the COMPANY affording coverage reserves the right to reject any application for any reason. If additional space is needed, attach details to application on a separate sheet of paper. All applicants must sign each application where indi-cated.
A APPLICANT INFORMATION
❑
New❑
Renewal1 Broker/Agent: Name __________________________________________________________________________________________ Address ______________________________________________________________________________________________________ City __________________________________________________ State ___________ Zip _____________ County ______________ FEIN # _______________________________________________ SSN# _________________________________________________ Telephone ____________________________________________ Fax ____________________________________________________ Email ________________________________________________ Producer Name _________________________________________ Proposed Effective Date ______________________________
2 Applicant Name (First Named Insured) ___________________________________________________________________________ DBA _________________________________________________________________________________________________________ Mailing Address _______________________________________________________________________________________________ City __________________________________________________ State ___________ Zip _____________ County ______________ FEIN # _______________________________________________ PC License # ___________________________________________ Telephone ____________________________________________ Fax ____________________________________________________ Loss Control Contact __________________________________ Accounting Contact _____________________________________ Category(ies) of License:
❑
GHP❑
Commercial Vertebrate❑
Fumigation❑
WDI/O❑
L&O❑
Other ____________________________________________________________________________________ Business Type:❑
Sole Proprietorship❑
Partnership❑
Corporation❑
LLC❑
Other ______________________________ B LIST OF LOCATIONS: List all locations here (including main location), address, city, state, and zip3 _____________________________________________________________________________________________________________ See page two to add additional locations.
C GENERAL INFORMATION—Explain all "Yes" responses below.
4 Is the Applicant a successor of any other business? ...
❑
Yes❑
No 5 Does Applicant own or operate any other business? ...❑
Yes❑
No 6 Is work done through or by any affiliated or related companies? ...❑
Yes❑
No 7 Does Applicant transport hazardous materials/substances in PLACARDED vehicles owned, leased, or rentedby Applicant? ...
❑
Yes❑
No If yes, attach procedures and describe all hazardous materials/substances transported.8 Do all drivers of PLACARDED vehicles maintain current Commercial Drivers Licenses? ...
❑
Yes❑
No 9 How many vehicles do you use to transport pesticides? ____________________________________________________________(Edition Date) 6/05 P.O. Box 440549 Local Telephone (678) 290-2100
Kennesaw, GA 30160 FAX (678) 290-2200 Visit Our Website at
10 Is Applicant, or any affiliated, related or predecessor entity currently involved in any litigation, administrative,
or arbitration proceeding(s) or subject to any court or agency order of injunction? ...
❑
Yes❑
No If yes, provide details in Section D.11 Has Applicant, or any affiliated, related, or predecessor entity or any officer or owner of any of them ever
been convicted of a crime? If yes, provide details in Section D. ...
❑
Yes❑
No 12 Has Applicant, or any affiliated, related, or predecessor entity ever been (or is currently) the subject ofbankruptcy, reorganization, solvency, dissolution, or other debtor related proceeding, or has it
made an assignment for the benefit of creditors? If yes, provide details in Section D. ...
❑
Yes❑
No 13 Has the applicant or any affiliated, related or predecessor entity ever been fined or disciplined by anygovernmental/regulatory agency or by civil court for violation of any regulations, safety, health or product
label, environmental laws or regulations? If yes, provide details in Section D.. ...
❑
Yes❑
No 14 Do you have any knowledge of or reason to expect claims to be filed arising out of pest control operationsprior to the effective date of coverage with the company? If yes, explain in Section D. ...
❑
Yes❑
No 15 Does Applicant perform building inspections or appraisals, or issue reports or render servicesor opinions regarding structural integrity, chemical, or air quality or health-related mold?
NOTE: THESE SERVICES, REPORTS, AND OPINIONS ARE NOT COVERED.. ...
❑
Yes❑
No D COMMENTS AND DETAILS16 Use this space to provide details of any questions answered Yes in Section C and/or other sections as necessary.
_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ List of additional locations: ___________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________
Exterminator Liability Application
Page Three
ALL QUESTIONS MUST BE ANSWERED! BLANK RESPONSES MEAN "0" OR "NONE"
E EXTERMINATION CONTRACTING SERVICE—$ OF RECEIPTS
16 Where are pesticides used for sales & services stored? ____________________________________________________________ 17 How many years have you been in the pest control industry? ______________Business is ________ years old
If in business less than two years, name and location of previous pest control employer _____________________________ _____________________________________________________________________________________________________________ 19 Breakdown of estimated annual receipts from all operations for which you or someone in your company is licensed. Place
check(s) next to the phase(s) in which you are licensed (total from all sources should equal gross receipts reported in 18).
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Lawn & Ornamental $ ________________________________❑
Pest Control $ ______________________________________❑
Wildlife Control $ ____________________________________ Section H Required❑
Termite Control $ ____________________________________ Receipts including treatments, annual renewals, and damage repair services—excludes fumigation and WDI/O (real estate) inspections❑
WDI/O Inspections $ ________________________________ Receipts from real estate inspections and reports only Estimated number of WDI/O inspections/reports (real estate only) performed annually _________________________________❑
Fumigation $ _______________________________________ Performed direct/in-house only; heat treatments & other details must be listed on Supplemental Application Page 4A and Sample Copy of Contract Required❑
Subcontracted Services $ ____________________________❑
Subcontracted Costs $ ______________________________❑
Net Subcontracted Receipts $ ________________________Explain in Section F and on Page 4A if subcontracted services include fumigation (please provide payroll for this exposure)
❑
Other Services (Payroll) $ ____________________________ Explain in Section G20 What percentage of termite control receipts are from carpentry, damage repair, restoration, etc? ______________________% 21 Is the pest control operation a full time business for Applicant? ...
❑
Yes❑
NoIf no, what is Applicant’s primary occupation? _____________________________________________________________________ 22 Do you sell pesticides in a retail operation? ...
❑
Yes❑
NoDo you reformulate or repackage pesticides for retail sale? ...
❑
Yes❑
No 23 Are you a member of any pest control associations? ...❑
Yes❑
No If yes, which one(s) ____________________________________________________________________________________________ 24 Do you conduct training programs for technicians? ...❑
Yes❑
NoIf yes, how often? _____________________________________________________________________________________________ 25 Number of employees: Pest Control _____ Termite Control (Treatment) _____ Fumigation _____
WDI/O (Real Estate) Inspection _____ Sales _____ Clerical _____ F SUBCONTRACTED SERVICES
26 Describe any services (fumigation, pest control, termite control, or other services) which are performed by subcontractors of Applicant _________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 27 Is Applicant an Additional Insured on the subcontrator's policies? ...
❑
Yes❑
No 28 Does Applicant obtain a waiver of Subrogation from the subcontractor? ...❑
Yes❑
NoG OTHER SERVICES (Explain on Page 4A, Section K “Subcontracted Services” if fumigation services are performed by a subcontractor of Applicant)
29 Does Applicant provide other non-pest control services such as Janitorial, Carpentry, Excavation/Grading,
Roofing, Plumbing or General Construction? ...
❑
Yes❑
No If yes, please describe below; description should include estimated volume of additional annual receipts generated by each non-pest control service ________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ H WILDLIFE CONTROL30 What type(s) of animal(s) are controlled/trapped? _________________________________________________________________ 31 What procedures, products, methods, and equipment (including the use of fire arms) are used in controlling/trapping?
_____________________________________________________________________________________________________________ 32 What release/extermination/disposal procedures or techniques (including the use of fire arms) are used for
trapped animals?
_____________________________________________________________________________________________________________ I DEDUCTIBLE DESIRED LIMITS DESIRED
33
❑
$500❑
$100,000❑
$300,000❑
$500,000/1,000,000❑
$1,000❑
$100,000/300,000❑
$300,000/600,000❑
$1,000,000❑
$2,500❑
$200,000/300,000❑
$500,000❑
$1,000,000/2,000,000Other deductible amounts considered upon request J CLAIMS HISTORY—LIST HERE
Have you had any claims during the past 3 years? (This includes all claims, whether or NOT reported to your insurer, or whether any payments were made. Currently valued, three-year loss runs must be attached to application.
Please list below. Check here if none:
❑
34 Date of Loss Description of Loss Amount Incurred $
_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Attach a separate sheet of paper, if necessary.
K CARRIER INFORMATION LAST 3 YEARS FOR GENERAL LIABILITY
35 Current Year ____________________________Carrier _________________________________ Premium $ ___________________ First Prior Year __________________________Carrier _________________________________ Premium $ ___________________ Second Prior Year _______________________Carrier _________________________________ Premium $ ___________________
M APPLICANT’S SIGNATURE
NOTICE TO COLORADO APPLICANTS: THIS NOTICE IS A PART OF YOUR APPLICATION FOR PROFESSIONAL LI-ABILITY INSURANCE: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment or both.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitation a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading informa-tion is guilty of a felony.
NOTICE TO UTAH APPLICANTS: For your protection, Utah law requires the following to be included in this application: “Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.”
For Florida Applicants only: Agent’s Name: _____________________________________ FL License Number: ________________
Any person who knowingly and with intent to defraud any insurance company or another person files an application 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, insur-ance benefits may also be denied.)
By acceptance of an insurance policy based on this application, the Insured 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 In-sured and the Company, or any of its agents, relating to this insurance. The InIn-sured acknowledges that this application is a part of the insurance policy.
Applicant’s Signature ______________________________________________________________ Date ______________________ Producer’s Signature ______________________________________________________________ Date ______________________
Must be completed and signed by Applicant and Producer if Fumigation of any type is performed. N FUMIGATION CONTRACTING SERVICES—$ OF RECEIPTS
36 Check types of contracting services Applicant provides, and provide the estimated contract volume during the next 12 months for each.
❑
Structures and Buildings Fumigants Used:Residential $ ______________________
❑
VikaneCommercial $ ______________________
❑
Methyl Bromide❑
Commodity $ ______________________❑
Heat Treatment _______________________________________❑
Ships/Barges $ ______________________❑
Other _______________________________________________❑
Aircraft $ ______________________ Total Fumigation Receipts $ _______________________❑
Agricultural Equipment $ ______________________ Total Fumigation Payroll $ _______________________❑
Other (describe) $ ______________________ 37 Fumigation Contractors—Security Provided:❑
Security and Safeguard Service is provided continuously from acceptance of risk by Applicant until released back to owner.Describe Acceptance and Return Procedure ______________________________________________________________________ _____________________________________________________________________________________________________________ Attach a copy of Certificate of Insurance from Security/Safeguard service.
Are locks and 24 hour on site security required by state law or regulation? ...
❑
Yes❑
No 38 Current employee list involved with fumigation—if none, so state:Owner, Officers & Years Applicator Expiration Categories
Employee Name Employed License # State Date Licensed
_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 39 Has the insured completed the DOW CTE or other similar program? ...
❑
Yes❑
NoIf so, please attach a copy of the certificate. APPLICANT’S SIGNATURE
Any person who knowingly and with intent to defraud any insurance company or another person files an application 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 acceptance of an insurance policy based on this application, the Insured 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.
Applicant’s Signature ______________________________________________________________ Date ______________________ Producer’s Signature ______________________________________________________________ Date ______________________
Termite & Pest Control Operators
General Liability Renewal Application
This general liability renewal application is to obtain certain information to determine a renewal quote. All other information provided in the most recent exterminator liability application will be considered unchanged and will be part of the renewal policy if written. Complete all blank fields; any remaining blank fields will mean “zero” or “none.”
1 Applicant’s Name _____________________________________________________________________________________________ 2 Company Name _______________________________________________________________________________________________ 3 Mailing Address _______________________________________________________________________________________________ City __________________________________ State __________ ZIP _____________ County _________________________________ 4 Policy Number _______________________________________ Renewal Date ____________________________________________ 5 Telephone Number __________________________ Federal I.D.# _____________________PC License # ___________________ 6 Loss Control Contact _________________________________ Accounting Contact _______________________________________ 7 Category(ies) of License: ❑ General Pest ❑ Commercial Vertebrate ❑ Fumigation ❑ WDI/O - Termites
❑ L & O ❑ Other ______________________________________________________________________________________________ 8 Business Type: ❑ Sole Proprietorship ❑ Partnership ❑ Corporation ❑ LLC ❑ Other
List of Locations _______________________________________________________________________________________________ _____________________________________________________________________________________________________________ 9 Deductible Desired:_________________ Limits Desired (Sublimits may apply):_________________
10 Breakdown of estimated annual receipts from all operations for which you or someone in your company is licensed. Place check(s) next to the phase(s) in which you are licensed.
❑
Lawn & Ornamental $ ________________________________❑
Pest Control $ ______________________________________❑
Wildlife Control $ ____________________________________ Section H Required❑
Termite Control $ ____________________________________ Receipts including treatments, annual renewals, and damage repair services—excludes fumigation and WDI/O (real estate) inspections❑
WDI/O Inspections $ ________________________________ Receipts from real estate inspections and reports only Estimated number of WDI/O inspections/reports (real estate only) performed annually _________________________________❑
Fumigation $ _______________________________________ Any change in business from expiring policy to perform direct/in-house or by subcontract requires completion of supplemental fumigation application.❑
Subcontracted Services $ ____________________________❑
Subcontracted Costs $ ______________________________❑
Net Subcontracted Receipts $ ________________________ List subcontracted services including fumigation ____________ _____________________________________________________________________________________________________________❑
Other Services (Payroll) $ ____________________________ Please list services provided _____________________________ _____________________________________________________________________________________________________________ 11 Do you have any knowledge of or reason to expect claims to be filed arising out of pest control operationsprior to the effective date of renewal? ...❑ Yes ❑ No If yes, please explain ___________________________________________________________________________________________
P.O. Box 440549 Local Telephone (678) 290-2100
Kennesaw, GA 30160 FAX (678) 290-2200 Visit Our Website at
WATS 800-476-4940 www.thomcoins.com
APPLICANT’S SIGNATURE
NOTICE TO COLORADO APPLICANTS: THIS NOTICE IS A PART OF YOUR APPLICATION FOR PROFESSIONAL LI-ABILITY INSURANCE: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment or both.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitation a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading informa-tion is guilty of a felony.
NOTICE TO UTAH APPLICANTS: For your protection, Utah law requires the following to be included in this application: “Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.”
For Florida Applicants only: Agent’s Name: _____________________________________ FL License Number: ________________
Any person who knowingly and with intent to defraud any insurance company or another person files an application 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, insur-ance benefits may also be denied.)
By acceptance of an insurance policy based on this application, the Insured 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 In-sured and the Company, or any of its agents, relating to this insurance. The InIn-sured acknowledges that this application is a part of the insurance policy.
Applicant’s Signature ______________________________________________________________ Date ______________________ Producer’s Signature ______________________________________________________________ Date ______________________ 12 Since submitting the most recent application, has Applicant become engaged in any
business other than pest control? ...❑ Yes ❑ No If yes, what type of business (include receipts for that business in Other Services above) _______________________________ _____________________________________________________________________________________________________________
AMERICAN SAFETY PURCHASING GROUP, INC. UNDERWRITTEN BY: AMERICAN SAFETY RISK (ASPG)
RETENTION GROUP, INC. 1845 THE EXCHANGE, SUITE 200
ATLANTA, GEORGIA 30339 Phone: (770) 916 -1908 Facsimile: MO) 916 -0618 . PEST CONTROL MEMBERSHIP APPLICATION
In accordance with the Liability Risk Retention Act of 1986, American Safety Purchasing Group, Inc. (ASPG) has been established as a. Risk Purchasing Group, organized and incorporated under the laws of the state of Georgia. ASPG was
I
I created to secure General Liability, Professional Liability and Pollution Liability insurance coverage for companies engaged in services that may present an enviromnental hazard.
I
Membership fee is a one -time $50.00 fee. The membership fee must be received by ASPG before policies are issued. Business Name (Applicant/insured):
Other-Corporation: Partnership: Sole Proprietor:
Mailing Address:
Telephone Number: Fax Number:
Contact Person:
Indicate Type of Services rendered:
X Other
Pest Control Operator
Describe:
Pleas e accept this application for membership in. the American Safety Purchasing Group, Inc. Membership is subject to ASPG's bylaws and rules and regulations.
Membership does not guarantee issuance or renewal of coverage. All coverage is dictated by terms of insurance policies.
The applicant hereby authorizes ASPG on applicant's behalf to *execute such documents and/or agreements as may be required to secure the insurance and reinsurance required in connection with the placement of this coverage. Please accept this application for membership in the American Safety Purchasing Group, Inc. It is understood that the $50.00 membership fee is a one -time fee due at policy inception and is non -refundable.
By: Date:
Title of Officer with Authority to Sign on Behalf of Applicant/Insured Environmental Remediation Contracting
