Step 1 of 7 14% EmailThis field is for validation purposes and should be left unchanged.Section I – Applicant InformationBusiness Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Telephone*Website* State(s) / Area of Operation*Licensed for Business in State(s)*Years in Business*Contractor License #:Name of Licensed Pest Control Operator/Applicator:*Are you a member of any pest control association?* Yes No Which one(s)?* Section II – Eligibility CriteriaDo you subcontract more than 25% of your gross receipts?* Yes No No past, pending or planned bankruptcy or judgments for unpaid taxes against the named insured or any officer, partner, member or owner of the applicant individually within the past (5) years* True False Do you perform Aerial Pesticide Application?* Yes No Do you perform Agricultural Plant/Animal Pest Control?* Yes No Do you perform Aquatic Pest Control?* Yes No Do you perform Bird Control/Extermination on or near airports?* Yes No Do you perform Crop Application – Spraying or Treatment?* Yes No Do you perform Demonstrate/Research Pest Control?* Yes No Do you perform Forest Pest Control?* Yes No Do you perform Fumigation involving tenting?* Yes No Do you perform Inspection and/or treatment for mold, fungus, etc?* Yes No Do you perform mixing or compounding of chemicals or products by, or at the direction of, an insured for the purpose of sale to others?* Yes No Do you perform Radon Analysis or Remediation?* Yes No Section III – Exposure HistoryPlease provide historical receipts, payroll and cost of subcontracted work.5th Prior YearAnnual Gross ReceiptsEmployee PayrollSubcontractor Costs*4th Prior YearAnnual Gross Receipts*Employee Payroll*Subcontractor Costs*3th Prior YearAnnual Gross Receipts*Employee Payroll*Subcontractor Costs*2th Prior YearAnnual Gross Receipts*Employee Payroll*Subcontractor Costs*Current YearAnnual Gross Receipts*Employee Payroll*Subcontractor Costs*Projected Next 12 monthsAnnual Gross Receipts*Employee Payroll*Subcontractor Costs* Section IV – Type of Work Performed1. Please indicate the percentage of clients that fall into the following categories:Commercial*Residential*Food Processor/Restaurant*Hospitality/Medical Facility*Educational/Daycare Facility*Other*2. Category(ies) Licensed in which to do business* General Household Pest Commercial Vertebrate Termite WDI/O Fumigation Lawn & Ornamental Other Other - Please specify* Section V – Description of Operations1. Please provide Gross Receipts and Payroll (including casual labor) for each trade performed by the applicant.Services as WDO/WDI inspector onlyEstimated Gross ReceiptsEstimated Gross PayrollExtermination: InsectsEstimated Gross ReceiptsEstimated Gross PayrollExtermination: Rodent/Animal RemovalEstimated Gross ReceiptsEstimated Gross PayrollExtermination: TermitesEstimated Gross ReceiptsEstimated Gross PayrollExtermination: MosquitoesEstimated Gross ReceiptsEstimated Gross PayrollExtermination: Bed Bugs – CommercialEstimated Gross ReceiptsEstimated Gross PayrollExtermination: Bed Bugs – ResidentialEstimated Gross ReceiptsEstimated Gross PayrollLandscape, Gardening, Pruning, Repairing, etc.Estimated Gross ReceiptsEstimated Gross PayrollFumigationEstimated Gross ReceiptsEstimated Gross PayrollIf fumigation is included, describe fumigation process and chemicals used:Carpentry/RepairsEstimated Gross ReceiptsEstimated Gross PayrollAny operations in any classes other than those listed above?* Yes No Please provide details, gross receipts and payroll*3. Termite/WDI3a. Do you engage in any drilling operations during pest control application?* Yes No What precautions are taken to avoid drilling into service lines: (i.e., gas, water, oil, etc.)*3b. Do you perform termite damage repair?* Yes No What percentage of termite work is repair work?*3c. Do you perform home inspections?* Yes No 4. Wildlife4a. Do you perform large animal control (such as alligators, bears, wild boars, wild cats, etc.)?* Yes No Please describe*4b. What release/extermination/disposal procedures are used for trapped animals?*4c. Are any firearms used for wildlife control?* Yes No Type and caliber?*4d. Do you perform repair work for animal damage?* Yes No 5. Bed Bugs5a. Experience of technicians and/or owner regarding bed bug eradication treatments*5b. Describe the detection, treatment and elimination procedures*5c. Are inspections/treatments/eliminations performed on any commercial entities such as hotels/motels, apartment complexes and other multi-residential buildings?* Yes No 5d. Do you use heat treatments?* Yes No 5e. Do you have a specific contract in place for bed bug treatment services?* Yes No • Does the contract provide any warranties or guarantees regarding bed bug treatments?* Yes No 6. Does the applicant provide interstate or highway right-of-way maintenance work?* Yes No 6a. How many years of experience do you have in this type of work?*7. Does the applicant use foam pesticides?* Yes No 7a. What types of pesticide applicator units do you use?* Can Hand Pumps Compressed Air 7b. What precautions are taken to prevent foam from seeping into unintended areas?*8. Does the applicant use EPA “restricted use” pesticides?* Yes No 8a. What is the applicant’s EPA license number?*8b. When and where are these chemicals used?*8c. Why is it necessary to use EPA “restricted use” pesticides?*9 . Are chemicals stored in NFPA approved containers?* Yes No Provide details of storage:*10. Are label directions for application and chemical amount strictly followed?* Yes No 11. Have you acted in the capacity of a General Contractor and/or Construction Project Manager on new ground-up residential construction (defined as apartments, condos, co=ops, homes or townhomes) in past 10 years?* Yes No 12. Do you have any contracts with new home developers or new home builders for the treatment or inspections of homes?* Yes No Please provide details on the number of contracts, number of homes per contract and specific duties (i.e., pest control, termite inspection, etc.) for each contract:* Section VI – Liability Controls / Risk Transfer1. Do you subcontract work?* Yes No 1a. Describe the type of work that is subcontracted*1b. Annual subcontracting costs*1c. Subcontractor Best Practices Followed?* Check all that apply Certificates of Insurance required from all subcontractors prior to starting work? Hold Harmless and Indemnification Agreements required for all subcontractors? Subcontractors required to carry primary limits equal to or greater than insureds? Subcontractors required to have their own Workers’ Compensation Insurance? 2. Does the applicant have a formal safety program in place?* Yes No 3. Do you conduct training programs for technicians?* Yes No 4. Are technicians trained on emergency spill control procedures?* Yes No 5. What quality control procedures are in place to ensure technicians complete forms correctly regarding chemical application?*6. Does applicant use a written contact with customers?* Yes No 7. Describe how warnings are communicated to customers prior to the application*8. Describe applicant’s follow-up procedures with customers after application has been applied*9. Pre-employment Screening procedures for employees*(Check all that apply.) Employment Application Background Check Drug/Alcohol Testing Verify Prior Experience Driving Record Applicator License Other 10. Do you have Workers’ Compensation coverage in force?* Yes No Please provide name of carrier and expiration date of coverage.* Section VII – Claim History1. 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 environmental laws or regulations?** Yes No Please describe*2. Does the Applicant 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 this company?* Yes No Please describe*3. Has your firm ever had its pesticide applicator license revoked or suspended?* Yes No Please describe*Supporting Documentation Drop files here or Select files Max. file size: 98 MB. Please upload any supporting documentation you feel may assist us in the underwriting of your insurance proposal.
