Liability Application First Named Insured:Other Named Insureds:Requested Policy Date:Fed ID #:Address:Phone #:*Cell #:Fax #:*Email:* Years In Business:IndividualPartnershipCorporationLLCIf 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:GHP-General Household/Commercial PC: Estimated Gross Receipts ($):Termites-Post Construction: Estimated Gross Receipts ($):Termites-Pre-Construction: Estimated Gross Receipts ($):Termites-Baiting Systems (Sentricon Etc.): Estimated Gross Receipts ($):Termites-Renewal Contracts: Estimated Gross Receipts ($):Structural Fumigation (Vikane Only): Estimated Gross Receipts ($):Lawn & Ornamental (Lawn & Tree Care): Estimated Gross Receipts ($):WDO/WDI Real Estate Inspections: Estimated Gross Receipts ($):Other Work (Janitorial, Carpentry, Gutter Cleaning Etc.): Estimated Gross Receipts ($):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. :YesNo2. Limits of Liability desired.:$300,000/$300,000$600,000/$300,000$500,000/$500,000$1,000,000/$500,000$1,000,000/$1,000,000$2,000,000/$1,000,000$3,000,000/$1,000,0003. Property Damage deductible desired? :$500$1,000$2,500Other4. 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?:YesNo9. Are all chemicals under lock & key?:YesNo10. Do you have spill kits for both your storage area & vehicle?:YesNo11. Do you private label chemicals for sale to customers?:YesNo12. Will you assume a termite renewal contract on properties you have not originally treated?:YesNo13. Have you had any "alleged" poisoning complaints in the past 3 years?:YesNo14. Have you been cited for any Governmental violations in the past 3 years?:YesNo15. If you're a fumigator, do you ever use Methyl Bromide?:YesNoPrior insurance carrier information and loss history for the past 3 years:Policy Year:Insurance Company:Liability Limits:Claims:Premium: