Pest Control and Wildlife Removal Insurance Questionnaire

Pest Control and Wildlife Removal Insurance Questionnaire
Applicant's Name: *
Address: *
Mailing Address
Address (cont): *
Mailing Address - continued
Contact: *
Email *
Telephone: *
Website
Fax:
Applicant is:

Individual Partnership Corporation Other (specify) Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
GENERAL INFORMATION

Please provide copy of customer contract and 5 years current loss runs.
1. How long have you been in business?
2. If new venture, describe experiences and qualifications in pest control industry?
3. In what states do you conduct business?
4a. Total annual sales ($)?
4b. Total annual payroll ($)?

4c. Please indicate number of employees:

	Full-Time	Part-Time
Number

Note: “Employees” include: Sole proprietors, Partners, Executive Officers, Seasonal employees, Part-time employees, Full-time employees.
5. Are you a member of any trade organizations?

Yes No
5a. If yes, please list:

6. What percentage of your work is:

	Commercial	Residential	Industrial
Percentage

7. Describe your employee training process, if applicable:
8. Does your pre-employment screening include background checks and drug testing?

Yes No

1. Please complete chart below of services you offer (include service as percentage of total operations, annual sales in $)

	Percentage of Operation	Annual Sales ($)
WDO/WDI Inspections
Bed Bug Treatment* - Complete questions below
Mosquito Abatement** - Complete questions below
Animal Trapping /Wildlife Control***- Complete questions below
General Pest Control (insect/rodent)
Fumigation Involving Tenting
Spraying or Treatment of Crops
Treating Bodies of Water
Bird Control at or Near Airports
Mold Inspections
Lawncare Services
Aerial Spraying or Dusting
Use of Explosives
Misting Systems/Mosquito Misters
Other (Describe in box below)

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2