Fillable Janitorial Services Product Application All States (Access E&S Insurance Services)

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Janitorial Services Product Application All States (Access E&S Insurance Services)

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Name Relationship/Interest Address City, State, Zip AI LP M
q q q
q q q
You can obtain a quote bY providing the information in Section i - inStant quote below, Subject to the remainder provided prior to binding.
JSA 08/10
page 1 of 2
Janitorial Services Product Application – All States
I. INSTANT QUOTE INFORMATION
Instant Quote is only available for accounts with no losses in the past three years. If there is loss history, please complete the entire application.
Applicant’s name: __________________________________________________________________________________________________________
Location address: __________________________________________________________________________________ q Same as mailing address.
City: ______________________________________________________ State: ______________________ Zip: ________________________
Description of Operations:
How many years has the applicant been at the current location? ____________________________________________________________
Which of the following will be cleaned during the policy term? (check all that apply): qResidences qOffices qMercantile (stores)
No work performed at mercantile locations when they are open for business, or accessible to the general public q True q False
Liability Section
Exposure Basis: # Full-time workers________________ # Part-time workers ______________
(include those with wages reported on 1099; part time is <30 hrs. per week)
Occurrence limit: q $100,000/$200,000 q $300,000/$600,000 q $500,000/$1,000,000 q $1,000,000/$2,000,000
Would you like to purchase coverage for Independent Contractors? q Yes q No
If “Yes,” what is the total annual cost $ _________
Would you like to purchase the property damage extension? q Yes q No
Do you want blanket additional insured coverage? q Yes q No
Additional Interests (AI = Additional Insured, LP = Loss Payee, M = Mortgagee)
Inland Marine Do you want to include inland marine coverage? q Yes q No
Contractor’s Equipment Floater Rental Reimbursement Lost Key Coverage
Blanket limit $10,000 Per day $250 Limit $25,000
Any one item $2,500 Any one loss $5,000
Deductible $500
II. LOSS INFORMATION FOR THE PAST 3 YEARS
Liability Coverages q None, or provide detail below.
Year Status Incurred Description
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
III. ELIGIBILITY CRITERIA
1. No past, present or future operations in Alaska or Louisiana q True q False
2. No handyman operations, including painting, plumbing or carpentry q True q False
3. No exposure to health care facilities (other than doctor’s offices) or assisted living facilities q True q False
4. No exterior operations over four stories q True q False
5. No handling of infectious waste or hazardous material q True q False
6. No more than 50% of total operations dedicated to floor waxing q True q False
7. No operations involving insurance claim response, water removal/extraction,
mold remediation, hood/duct cleaning or security q True q False
8. No operations on buses, trains or airplanes or in terminals/stations q True q False
9. No products sold under applicant’s name or label q True q False
10. No street cleaning or debris removal operations q True q False
11. No operations at locations other than residential, mercantile and office locations q True q False
12. Not over 25% of sales for operations involving landscaping, lawn maintenance, carpet cleaning
and window cleaning (combined) q True q False
13. Not subcontracting more than 25% of annual sales to independent subcontractors q True q False
14. No past, pending or planned bankruptcy or judgement for unpaid taxes against, the named insured
or any officer, partner, member or owner of the applicant individually within the past five years q True q False
Independent Contractor Eligibility
1. Certificates of insurance are obtained from all independent contractors q True q False
USLI.COM
888-523-5545
IV. ADDITIONAL APPLICANT INFORMATION
Form of business: q Individual q Corporation q Partnership q LLC q Other ____________________________
Number of years in business? ___________________________________
Applicant’s mailing address: ____________________________________________________ (if different than the location address above)
City: _________________________________________________________________________ State:___________________ Zip:________________
E-mail address of primary contact: _____________________________________________ Phone: ____________________________________
Inspection contact name: _______________________________________ Telephone/E-mail address: ___________________________________
Contact language preference: q English q Spanish Other ___________________________________________________________
Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of
the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.”
Colorado Fraud Statement: 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
District of Columbia Fraud Statement: 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.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the
admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Kentucky Fraud Statement: 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.
Maine and Washington Fraud Statement: 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.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
New York Fraud Statement: 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.
Ohio Fraud Statement: 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.
Oklahoma Fraud Statement: WARNING: 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 information is guilty of a felony.
Pennsylvania Fraud Statement: 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.
Tennessee and Virginia Fraud Statement: 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.
Fraud Statement (All Other States): 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 may be
guilty of a crime and may be subject to fines and confinement in prison.
Applicant’s signature: ____________________________________________ Title: _________________________ Date: _________________________
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name:
_______________________________________________________________________ License #: ___________________________
Main agency phone number:
____________________________________________________________________________________________________
Agency mailing address:
_________________________________________________________________________________________________________
City: ________________________________________ State: __________________ Zip code: ___________________________
JSA 08/10 - United States Liability Insurance Group
page 2 of 2
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Janitorial Services Product Application All States (Access E&S Insurance Services)

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Completed 8 January 2021

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