Fill - Free fillable PEST CONTROL SERVICES SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies) PDF form

PEST CONTROL SERVICES – SUPPLEMENTAL APPLICATION

GENERAL INFORMATION

Applicant’s Name:

(Complete company name as it should appear on the policy, including Inc., Corp., Ltd., etc.)

Mailing Address:

City:

State:

Zip:

Location Address:

Telephone Number:

Contact for Inspection/ Audit:

E-mail Address:

Website Address: www.

FEIN:

License number:

Risk Management Contact:

Risk Management’s Phone:

Risk Management’s Email:

GENERAL UNDERWRITING

Desired effective date:

Prior insurance carrier:

Prior year’s receipts: $

Prior year’s premium: $

How long has the Applicant been in business?

Have there been any changes in ownership, name or business operations in the last three years?

Yes

If yes, please explain:

Is the owner active in the business?

Yes

Please describe duties:

List Applicant’s three (3) largest clients:

Who are the Applicant’s customers? (Provide percentage)

Commercial: %

Residential: %

Is the Applicant a member of the Pest Control Association?

Yes

If yes, which state(s) is Applicant a member of?

Does the Applicant engage in any business other than pest control?

Yes

If yes, explain:

Does the Applicant engage in any drilling operations as regards to pesticide applications?

Yes

If yes, what precautions are taken to avoid drilling into service lines: (i.e. gas, water, oil, etc.)

10.

Are warnings posted prior to work performed?

Yes

11.

How long does the Applicant maintain records on work performed?

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12.

Describe procedures used by the Applicant to ensure subcontractors are adequately insured and

supply proof of insurance to the Applicant:

13.

Does the Applicant provide WDO/ WDI inspections?

Yes

Average amount of time spent performing a pest inspection:

Hours

Minutes

Number of inspections performed annually for real estate closings:

14.

Has the Applicant ever performed treatments or inspections to homes constructed with any type of

exterior insulation finishing system or synthetic stucco system?

Yes

If yes, number of homes treated:

If no, how does the Applicant avoid treating such structures:

15.

Are all areas of buildings with wet pipe sprinkler systems (hidden or unhidden) maintained

at a minimum temperature of 40° F, and / or provided with proper insulation or heat tracing

to prevent pipe freeze-ups?

N/A

Yes

BEDBUG TREATMENT AND INSPECTION

N/A

Describe the detection method. If dogs are used, how many?

Describe the inspection, treatment and elimination procedures:

Does the Applicant use heat treatments?

Yes

If yes, complete questions a through e:

Prior to conducting the work, are applicable fires codes and local ordinances checked

regarding the use of portable heaters, existence of fire suppression systems and other heat

treatment related concerns?

Yes

Is the heat treatment equipment inspected prior to use?

Yes

What steps are taken to protect the fire suppression systems that are present at a job site?

Are objects and flammables removed from the treatment area?

Yes

Is a pre-work checklist completed and signed by the technician prior to completing the work?

Yes

If yes, please attach a copy.

Are inspections/ treatments/ eliminations done on any commercial entities, such as hotels/ motels,

apartment complexes or other multi-residential buildings?

Yes

If yes, Applicant must provide a copy of its commercial bed bug contract indicating no

warranties or guarantees are provided.

PERSONNEL/ TRAINING

How many employees (excluding owners) are employed?

Clerical:

Technicians:

Sales:

Total:

Describe the Applicant’s training program:

Are all technicians licensed and certified?

Yes

If no, please explain why they are not:

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What pre-employment screening procedures are being done on new hires?

SALES AND CHEMICAL INFORMATION

Operations and Services

Estimated

Gross Receipts

Estimated

Gross Payroll

Insects

Rodent

Termite Treatments

WDO/ WDI inspections

Mosquitoes

Bed bugs – Commercial

Bed bugs – Residential

Lawn Care Services including Spraying and Fertilizing

Tree Trimming & Fumigation, including Spraying and Repair

Fumigation*

Radon testing

Other operations (specify below)**

Subcontracted work

Cost (actual amount paid to subcontractor): $

What is the total receipt amount: $

What is the total payroll amount: $

* If fumigation is included, describe fumigation process and chemicals used:

** Other Operations Descriptions:

CHEMICALS

Are chemicals stored and handled as received from the manufacturer?

Yes

If no, what alterations are made prior to use:

Are chemicals stored in manufacturers’ containers in a separate building?

Yes

If yes, describe building:

Describe precautions used by the Applicant to secure chemicals.

Does the Applicant engage in retail sale of chemicals or other pest control items?

Yes

If yes, describe the products being sold:

Is there any alteration of manufacturer chemicals prior to sale to consumers?

Yes

What is the total volume of retail sales: $

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FRAUD STATEMENT AND SIGNATURE SECTIONS

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief

and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true

and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes

prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the

quote or binder.

The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company

VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,

MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN

EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.

FRAUD NOTICE STATEMENTS

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 AND SUBJECTS THAT PERSON TO

CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY

BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS

($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,

NM, OK, PA, RI, TN, VA, VT, WA AND WV).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN

APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.

APPLICABLE IN COLORADO: 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.

APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER

FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A

FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).

APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE

PRESENTED 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 STATEMENT 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 CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.

APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS

FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF

MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

APPLICABLE IN MAINE, 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. PENALTIES MAY INCLUDE IMPRISONMENT,

FINES OR A DENIAL OF INSURANCE BENEFITS.

APPLICABLE IN PENNSYLVANIA: 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.

APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH

SUCH VIOLATION.

NAME (PLEASE PRINT/TYPE) TITLE

(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE

DIRECTOR)

_____________________________________________________________

SIGNATURE DATE

SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT

PRODUCER AGENCY

(If this is a Florida Risk, Producer means Florida Licensed Agent)

PRODUCER LICENSE NUMBER

(If this a Florida Risk, Producer means Florida Licensed Agent)

ADDRESS (STREET, CITY, STATE, ZIP)

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CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL

QUESTIONNAIRE

Name of Applicant:

Address of Applicant:

City: State: Zip:

Website: www:

Nature of Operations:

1. Annual sales or revenue: $

2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)

belonging to customers, clients, or other third parties, other than employees?

If yes, please indicate the types of Personally Identifiable Information held (check all that apply):

Yes No

a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or

other State Identification Numbers

b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)

c. Credit or Debit Card Information

3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for

damage to their computer system(s) arising out of the operation of the Applicant’s computer

system(s)?

Yes No

b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a

lawsuit against t

he Applicant alleging

invasion or interference of rights of privacy or the

inappropriate disclosure of Personally Identifiable Information (PII)?

Yes No

c. During the last three (3) years, has the Applicant been the subject of an investigation or

action by any regulatory or administrative agency for privacy-related violations?

Yes No

d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a

claim being made against them for the coverage being applied for?

Yes No

PI-CYBE-APP (11/16)

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