P.O. Box 2489
Lake Ronkonkoma, NY 11779
Tel: 877.286.9154
Fax: 631.981.2233
Warner-Lane Associates Inc.

Liability Application

First Named Insured: Other Named Insureds:
Requested Policy Date:
Fed ID #:
Phone #: Cell #: Fax #:
Email: Years In Business:
Individual Partnership Corporation LLC
If in business less than 3 years please complete the following:
Previous Employer: City:
Position(s) Held:
Employment Start Date: End Date:
List Officers/Owners Names: % of Ownership: F/T or P/T: PC License #:
Classification: Estimated Gross Receipts ($):
GHP-General Household/Commercial PC:
Termites-Post Construction:
Termites-Baiting Systems (Sentricon Etc.):
Termites-Renewal Contracts:
Structural Fumigation (Vikane Only):
Lawn & Ornamental (Lawn & Tree Care):
WDO/WDI Real Estate Inspections:
Other Work (Janitorial, Carpentry, Gutter Cleaning Etc.):
Total All:
1. If you subcontract work are certificates of insurance with equal to or greater limits than yours obtained and are you named as Additional Insured. :
2. Limits of Liability desired.:
3. Property Damage deductible desired? :
4. List # of technicians:
5. Length of Training for new techs?:
6. Type of continuous training for services techs:
7. Where are chemicals stored?:
8. Do you have a program for housekeeping in the storage area?:
9. Are all chemicals under lock & key?:
10. Do you have spill kits for both your storage area & vehicle?:
11. Do you private label chemicals for sale to customers?:
12. Will you assume a termite renewal contract on properties you have not originally treated?:
13. Have you had any "alleged" poisoning complaints in the past 3 years?:
14. Have you been cited for any Governmental violations in the past 3 years?:
15. If you're a fumigator, do you ever use Methyl Bromide?:

Prior insurance carrier information and loss history for the past 3 years:
Policy Year: Insurance Company: Liability Limits: Claims: Premium:
Web Hosting Companies