Tree Trimmer's Application

1
Your contact info* This field is required.
Please enter your full name
Please enter your business name
Please enter your email
Please enter your phone
Please enter your address
2
New quote or renewal?
New quote
Renewal
3
Are you licensed where required by law?
YESNO
4
Please provide your license number:
5
Desired effective date:
6
Brief description of operations:
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Ok
7
Years in business, Years of experience in the industry:
8
Number of active owners/officers/partners:
9
Number of employees (W2):
10
Estimated gross receipts/revenue:This is used for the underwriter to gauge the size of your business and how they will determine your premium costs. Your gross receipts are subject to audit at the end of your policy term.
11
W2 payroll (excluding owner):
12
Do you subcontract work?
YESNO
13
Do you require certificates of insurance from subs?
YESNO
14
Do subcontractors name you as an additional insured?
YESNO
15
Sub costs (of those insured with equal or greater limits):
16
Uninsured/1099 sub costs:
17
List sub trades used:
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Ok
18
Do you carry Workers' Comp on temporary employees?
YESNO
19
Do you lease employees from others?
YESNO
20
If you do have leased employees, how much is their payroll?
21
List equipment owned or leased:
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Ok
22
Do you have regular service/maintenance schedule for all appointment?
YESNO
23
Do you perform stump removal or grinding?
YESNO
24
If you perform stump removal or grinding, explain your process:
25
Do you use any pesticides or herbicides not approved by the EPA?
YESNO
26
Do you use any explosives?
YESNO
27
Do you perform any logging or lumbering?
YESNO
28
If you do perform logging or lumbering, provide payroll and gross receipts for that work:
29
Do you work on interstates?
YESNO
30
Do you conduct pre-job surveys to locate overhead wires?
YESNO
31
Do you conduct pre-job surveys to locate overhead wires?
YESNO
32
Do you perform any work for any utilities?
YESNO
33
If you do work on utilities, please list them:
34
Prior Insurance Coverage
Current or prior insurance carrier
Any losses in the past 5 years, if yes please describe
Target price/current premium. this is optional but helps us shop for you
35
If you have your loss runs, you can upload them here:
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
36
Anything else we should know about your operations?
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Ok
Should be Empty: