Fillable Member Companies Of Western World Insurance Group (Abram Interstate Insurance)

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Member Companies Of Western World Insurance Group (Abram Interstate Insurance)

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Page 1 of 2 A53 (08/14)
Tree Trimming, Landscape
Gardening & Lawn Care Services
General Liability Supplemental Application
(Complete in addition to ACORD)
1.
Name of Applicant:
Website:
GENERAL
2.
Check all operations that apply and indicate annual payroll for each:
CLASSIFICATION
ANNUAL PAYROLL
Tree pruning, dusting, spraying, trimming or fumigating
$
Landscape gardening
$
Lawn care services
$
Snow removal
$
Lawn sprinkler installation, service or repair
$
Masonry "hardscaping"
$
Stump grinding
$
Total Annual Payroll
$
3.
Gross Annual Sales:
$
4.
Show percentage of work in:
Residential:
%
Commercial:
%
5.
If a new venture describe previous experience:
6.
Number of:
Active owners:
Full-time employees:
Part-time employees:
7.
Do you use subcontractors?
Yes
No
If yes, please answer questions a. through i.
a.
List all types of work that you subcontract:
b.
Annual subcontracted cost (labor and materials):
$
c.
General Liability limits required of your subcontractors:
$
/
d.
Business Auto Liability limits required of your subcontractors:
$
/
e.
Are you an Additional Insured on all subcontractors' CGL policies?
Yes
No
f.
Are you an Additional Insured on all subcontractors' Auto policies?
Yes
No
g.
Do subcontractors contractually hold you harmless?
Yes
No
h.
Do you obtain and keep copies of all certificates of insurance, evidencing subcontractors’
insurance coverage?
Yes
No
i.
Please attach a sample copy of agreements with subcontractors (insurance requirements, additional insured
requirements, and indemnification/hold harmless wording).
8.
Are you currently working or would you consider working in the state of New York?
Yes
No
9.
Type of license held:
Expiration date of license:
LANDSCAPING & TREE TRIMMING
Not Applicable
10.
Are you a licensed herbicide/pesticide applicator?
Yes
No
11.
List all chemicals used:
12.
Provide details of chemical storage and EPA number:
13.
Do you manufacture or sell any chemicals?
Yes
No
Page 2 of 2 A53 (08/14)
14.
List all equipment used:
15.
Any landscaping or tree removal performed alongside:
Airports
Interstate highways
Local public roads
Medians
Private roads
Railroads
State highways/roads
Thruways
16.
Do you use "Dig Safe" or similar safety measures prior to any digging?
Yes
No
17.
Do you perform utility line clearance work?
Yes
No
18.
Do you do any out-of-state storm clean-up work?
Yes
No
19.
Have you ever been contracted by any government agency to perform storm clean-up?
Yes
No
20.
Are you contracted by any municipalities to perform roadside tree trimming services?
Yes
No
21.
If working near electrical wires, are the lines shut down by the electric company prior to cutting?
Yes
No
22.
Do you use explosives?
Yes
No
NOTE: If there are any snow or ice removal exposures, please complete Western World
Application A105.
REMINDER: ACORD APPLICATIONS A125 AND A126 MUST BE COMPLETED
AND ATTACHED IN ORDER TO OBTAIN A QUOTE.
Applicant's Signature
Date
Title
Producing Agent
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Member Companies Of Western World Insurance Group (Abram Interstate Insurance)

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Completed 10 July 2021

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