Fillable EV Pest Control Supplemental Application (Kinsale Insurance)

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EV Pest Control Supplemental Application (Kinsale Insurance)

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Page 1 of 6
PEST CONTROL AND PESTICIDES SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
Agency/Agent:
Renewal?
Yes No
Policy Number:
Effective Date:
Website:
2) Current Carrier Information:
Carrier:
Limit of Insurance:
Deductible:
Premium:
Offering renewal?
Yes No
Claims made?
Yes No Retroactive date:
Please attach copies of the following:
a) Currently valued five year loss runs, including claim detail for all losses open or exceeding $15,000
b) MSDS sheets for all products sold, distributed or used by or on your behalf
c) Applicant’s brochures or marketing materials if a website is not available
3) Mailing Address:
City: State: Zip Code:
4) Your premise address (if different from above):
City: State: Zip Code:
5) If you work or subcontract out services in any state other than your premise location, please list the states in which
you operate:
6) If any subsidiary, product or service is to be specifically excluded from coverage, please indicate:
Are these products or services insured or bonded elsewhere? Yes No
7) If you have operated under a different business name in the last ten years, please list:
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
8) Please provide a breakdown of your operations:
Operation:
Projected Sales:
Percentage of Sales:
Bed Bug Treatment
Crop Dusting, Spraying or Other Agricultural
Application
Lawn Care Services – Including Fertilizing/Soil Nutrient
Amendment Application
Rodent/Small Animal Removal (mice, rats, squirrels,
chipmunks, raccoons, snakes, bats, etc.)
Large Animal Removal/Control (bears, alligators, wild boars,
bobcats, venomous snake dens, etc. – please provide details below)
Exterminating
Fumigation
Tenting
Inspections Performed as Part of a Real Estate
Transaction
Termite Inspections Without Treatment (excluding
inspection reports for previously treated homes and inspections as part
of a Real Estate transaction)
Termite Treatment
Radon Testing
Radon Remediation
Mold Inspection
Mold Remediation
Infestation Damage Repair (please provide details below)
Other (please describe below)
Total:
100%
9) Do you use gas to treat/control termites? Yes No
10) Do you provide any termite repair warranties, bonds, or contracts? Yes No
11) Describe your bed bug inspection and elimination procedures:
GENERAL OPERATIONS
TERMITES
BED BUGS
Page 3 of 6
12) Do you utilize heat treatment procedures? Yes No
a. If yes, prior to conducting work are applicable fire codes and local ordinances Yes No
checked regarding the use of portable heaters, existence of fire suppression
systems, and other heat treatment related concerns?
b. Is the heat treatment equipment inspected prior to each use? Yes No
c. Are all objects and flammable items removed from the treatment area? Yes No
d. Is a pre-work checklist completed and signed by the technician prior to Yes No
completing the work?
e. What steps are taken to protect the fire suppression system in place at the job site and prevent accidental
deployment of the system?
13) Do you utilize Cryo/Freeze method procedures? Yes No
14) Do you utilize chemical treatment methods? If yes, please list chemicals used. Yes No
15) Do you perform inspections, treatments, or eliminations at any commercial locations Yes No
(including but not limited to retail shops, hotels/motels, casinos, apartment housing, etc.)
or multi-residential buildings (condominiums, townhouses, duplexes, etc.)?
a. If yes, does your contract confirm to the client that there are no warranties or Yes No
guarantees provided?
b. Are any written instructions provided to the client regarding laundering or Yes No
other handling of textiles? If yes please provide a copy.
16) Are clients directed to remove valuables prior to treatment? Yes No
17) Please indicate the percentage of work performed in _____% residential, _____% commercial and _____% industrial
areas.
18) Do you engage in any drilling operations as part of your pesticide application process? Yes No
If yes, please clarify what precautions are taken to avoid drilling into service lines:
19) Do you use firearms for any part of your pest control services? Yes No
20) Do perform any bird control/extermination at or near airports? Yes No
21) If you provide commercial/industrial pest control, fumigation, extermination or tenting services, please list the type(s)
of clients and where on their premise(s) the work is performed:
22) Do you perform services for restaurants, cafeterias/dining halls, or bakeries? Yes No
If yes, do you conduct all spraying and treatment when the location is closed? Yes No
23) Do you perform any foaming operations? Yes No
a. If yes, are foam blasters manual/hand powered OR electric/battery powered ?
b. Describe precautions taken to prevent foam from escaping into unintended areas:
GENERAL PEST CONTROL
Page 4 of 6
24) Do you utilize dogs or other trained animals for inspections? Yes No
25) Do you currently, or have you ever, utilized any EPA restricted-use pesticides? Yes No
a. If yes, provide your EPA license number:
b. Attach a sheet describing where and when EPA restricted-use pesticides are used, why the use of EPA
restricted-use pesticides is necessary, and what specific pesticides are used in these circumstances.
26) Do you utilize any drones in your servicing? Yes No
27) Do you utilize glycophosphate products in your servicing? Yes No
28) Do you utilize 1,3-dichloropropene or chloropicrin products in your servicing? Yes No
If yes and you are working in California, do you utilize alternative products in that state? Yes No
29) Do you utilize any manned aircraft or drones in your servicing? Yes No
30) Do you typically hire the same subcontractors from job to job? Yes No
31) Are subcontractors always insured? Yes No
If yes, what General Liability limits do you require subs to carry?
32) Do you obtain certificates of insurance from all subcontractors? Yes No
If yes, how long are these retained?
33) Are you named as an Additional Insured on all subcontractors’ policies? Yes No
34) Do you have a written contract with your subcontractors? If yes, provide a sample copy. Yes No
Do all contracts contain a Hold Harmless clause in your favor? Yes No
35) Do you use any leased employees? Yes No
If yes, are you responsible for providing Worker’s Compensation for Yes No
these employees?
36) Do you carry Worker’s Compensation insurance? Yes No
37) Is your premise located in area that is:
Urban Rural Industrial Suburban Other (please clarify below)
38) Please clarify neighboring occupancies within 100 feet of your premise:
North
South
East
West
Occupancy
Distance
39) Are explosives or flammables stored or processed on site, including but not limited to Yes No
fertilizers?
a. If yes, please list product(s) and quantity:
b. Are explosive/flammable materials stored in NFPA/IFC compliant containment? Yes No
AGRICULTURAL
SUBCONTRACTORS
PREMISES INFORMATION
Page 5 of 6
40) Have you had any claims or suits that were or were not covered by insurance? Yes No
If yes, please provide details.
41) During the past five years, has any insurer ever canceled or non-renewed similar Yes No
insurance to any applicant or has your insurance been canceled for nonpayment of
premium by any insurance or finance company. If yes, please explain.
42) Is your company aware of any occurrences, facts, circumstances, incidents, situations, Yes No
damages or accidents (including but not limited to allegations of faulty or defective products
or workmanship, product failure, service contract or construction dispute, property damage
or service/construction worker injury) arising out of or related to your products or services
that a reasonably prudent person might expect to give rise to a claim or lawsuit whether
valid or not which might directly or indirectly involve the company? If yes, attach an explanation.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
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 KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
OTHER
Page 6 of 6
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating 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 a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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EV Pest Control Supplemental Application (Kinsale Insurance)

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Completed 16 July 2020

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