Pest Control Pro Application

Proposed Effective Date *

Named Insured *

DBA

Street Address 1 *

Street Address 2

City *0 / 100

State *

Postal Code *0 / 6

Primary Contact Name *

Business Phone *

Email *

Website Address

Current carrier and Limit of Liability

Is this policy being non-renewed? (N/A In Missouri) *YesNo

If yes, why? *Carrier no longer writing this coverageLoss historyOther

Other *

Date business started under current ownership (Month) *

Date business started under current ownership (Year) *

Do you own or operate any other business? *YesNo

If yes, explain *

Medical Payments Coverage: $5,000

Employment Practices Liability Limit (Not available in HI and LA) If coverage is desired, complete the following:

Employee Benefits Liability - If coverage is desired *YesNo

Employee Benefits Liability

Number of employees per location

FT employees

PT employees

FT volunteers

PT volunteers

Which services do you provide at this location?

Pest ControlYes

Gross Sales *

Bed BugsYes

Gross Sales *

FumigationYes

Structural Gross Sales *

Commodity Gross Sales *

Wild lifeYes

Gross Sales *

Termite treatmentYes

Gross Sales *

WDI/O inspectionsYes

Gross Sales *

Lawn Care ServicesYes

Gross Sales *

Retail salesYes

Gross Sales *

Other servicesYes

Cost *

Gross Sales *

Description *

Net retained *

Sub Contracted servicesYes

Gross Sales *

Cost *

Description *

Net retained *

How many employees are employed?

Clerical

Techs

Sales

Do you have a formal safety program? *YesNo

Do you conduct training programs for technicians? *YesNo

Do you belong to any state or national associations?YesNo

If yes, please list *

Where and how are pesticides stored? *

Have any crimes been committed on your premises within the past 3 years? *YesNo

Any bankruptcies, tax or credit liens against you in the last 5 years? *YesNo

Has the account been cancelled and reinstated more than 3 times in the last 12 months? (N/A in Missouri) *YesNo

Have you or any affiliated related or predecessor entity or any officer or owner been convicted of a felony? *YesNo

Have you or any affiliated related or predecessor entity ever been fined or disciplined by any governmental regulatory agency for violation of regulations, safety, health or product label, environmental laws or regulations? *YesNo

Are label directions for application and chemical amount strictly followed? *YesNo

Do you mix chemicals of others and place your labels on them? *YesNo

If yes, provide details *

Termite/WDI

Termite/WDI

Do you engage in drilling operations during treatment? *YesNo

If yes, what precautions are taken to avoid drilling into service lines? *

Do you perform termite damage repair? *YesNo

If yes, what percentage of termite work is repair work? (%) *

Do you perform home inspections? *YesNo

Wildlife

Wildlife

What release/extermination/disposal procedures are used for trapped animals? *

Are any firearms used for wildlife control? *YesNo

If yes, type and caliber *

Do you perform repair work for animal damage? *YesNo

Subcontractor

Subcontractor

Do you verify subcontractors are adequately insured and obtain current Certificates of Insurance? *YesNo

Do you require subcontractors to name you as an Additional Insured? *YesNo

Do you require the subcontractor to provide you with a waiver of subrogation? *YesNo

Have you had any claims or losses in the past five years? This includes both claims that you have filed and losses you did not file with an insurance company.YesNo

Are you involved in any litigation, administrative, or arbitration proceedings or subject to any court or agency order of injunction?YesNo

If yes, explain *

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 the Company?YesNo

If yes, explain *

List all losses in the past 3 years whether or not insured (Attach additional sheet if necessary)

Date of Claim

Type of Claim

Open/Closed

Amount Paid

Description of Claim

STATE FRAUD STATEMENTS

Applicable in AL, AR, DC, LA, MD, NM, RI and WV

Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only.

Applicable in CO

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.

Applicable in FL and OK

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.

Applicable in KS

Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in KY, NY, OH and PA

Any person who knowingly and with intent to defraud any insurance company or other 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 such person to criminal and civil penalties* (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only.

Applicable in ME, TN, VA and WA

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.

Applicable in NJ

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Applicable in OR

Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

Applicant’s signature *

Date *

How did you hear about us?

Describe *

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