Fillable EXTERMINATORS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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EXTERMINATORS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-4s (9-16) Page 1 of 5
EXTERMINATORS GENERAL LIABILITY APPLICATION
Applicant’s Name:
Mailing Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE:
From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Limits Of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations) $
Products and Completed Operations Aggregate $
Personal and Advertising Injury (any one person or organization) $
Each Occurrence $
Damage To Premises Rented To You (any one premise) $
Medical Expense (any one person)
$5,000 (included)
Other: $
In-Transit Pollution Coverage $25,000/$100,000 (included)
Lost Key Coverage $25,000/$25,000 (included)
Pesticide/Herbicide Applicator Coverage (Included up to GL limits) $
Property Damage Extension (CCC) Occurrence
(Included for limits equal to GL limits up to $200,000/$300,000) Aggregate
$
$
Wood Destroying Organism Inspection Coverage
$25,000/$100,000 (included)
$50,000/$100,000
Other: $
Other Coverages, Restrictions, and/or Endorsements:
$
Deductible $
GL-APP-4s (9-16) Page 2 of 5
Website Address:
E-mail Address: Phone Number:
1. Location Of Operations:
Street Address and City State License Number
1. Same as mailing address
2.
3.
2. How long has applicant been in business? years Full-time Part-time
3. Employee Data:
Category Owner(s) only
Exterminators:
Full-time
Exterminators:
Part-time
Total
Number
4. Does applicant subcontract work? .......................................................................................................... Yes No
If yes: Annual subcontract cost: ............................................................................................................... $
Type of work subcontracted:
Are Certificates of Insurance obtained? ........................................................................................ Yes No
Minimum limits that subcontractors are required to carry:
5. Description Of Operations:
Operation Sales
Percentage of
Gross Sales
Termite Inspections without Treatment (do not include sales for renewal
inspections where a previous treatment by applicant has been done)
$ %
Termite Treatment and Renewal Inspections $ %
Carpentry (Payroll: $ ) $ %
Exterminating—Residential
Commercial
$
$
%
%
Fumigation—Residential
Commercial
$
$
%
%
Crop Dusting or Spraying $ %
Tenting $ %
Highway Right of Way Maintenance $ %
Other—Describe:
$ %
Total Sales
$ 100%
6. Does applicant perform large animal control (such as alligators, bears, lions)? ............................... Yes No
If yes, explain:
7. Does applicant exterminate other than insects or small household pests? ....................................... Yes No
If yes, explain:
GL-APP-4s (9-16) Page 3 of 5
8. Does applicant perform bird control/extermination at or near airports? ............................................ Yes No
9. Does applicant install and/or repair insecticide misting systems? ..................................................... Yes No
10. Does applicant perform radon testing? .................................................................................................. Yes No
If yes, describe the procedure:
Who performs the analysis?
If yes, describe:
11. Does applicant eliminate pests by:
a. Igniting flammable substances? ............................................................................................................ Yes No
b. Use of guns? ......................................................................................................................................... Yes No
c. Use of explosives? ................................................................................................................................ Yes No
12. Does applicant inspect for mold? ............................................................................................................ Yes No
13. Does applicant advise clients if he/she does not inspect for mold? ................................................... Yes No
14. Does applicant perform any mold or spore remediation? .................................................................... Yes No
15. Does applicant subcontract mold remediation? .................................................................................... Yes No
16. Additional Insured Information:
Name Address Interest
17. During the past three years, has any company canceled, nonrenewed, declined or refused simi-
lar insurance to the applicant? (Not applicable in Missouri) .................................................................... Yes No
If yes, explain:
18. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?.................................................................................................... Yes No
If yes, describe:
19. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
20. Prior Carrier Information:
Year: Year: Year:
Carrier
Policy No.
Coverage
Total Premium
GL-APP-4s (9-16) Page 4 of 5
21. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior three years. Check if no losses in the last three years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
$ $
$ $
$ $
$ $
$ $
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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 applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 state-
ment 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 con-
ceals, 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.
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 sub-
ject to fines and confinement in prison.
GL-APP-4s (9-16) Page 5 of 5
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 a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who 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.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND 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.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK FRAUD WARNING: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim
for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
PRODUCER’S ADDRESS:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
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EXTERMINATORS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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