| Company |
Corp LLC Sole Prop. Partnership |
| Contact : |
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| Address: |
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| address cont. |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Phone: |
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| FAX |
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| Email: |
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| Website: |
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| Years In Businsess (Min 2 even if not insured) |
years in business |
| If in business less than 3 years, name and location of previous employer |
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| Years Experience: |
experience |
| Effective Date: |
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| * Federal Tax ID or SS #: |
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Current Insurance Carrier/s
(not agent) |
no insurance |
| BREAKDOWN OF OPERATIONS |
PAYROLL (estimated annual) |
| Landscape Maintenance Payroll: |
$ |
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| Landscape Constuction: |
$ |
| Snow Plowing: |
$ |
| Chemical Applications: |
$ |
| Tree Work: |
$ |
| Irrigation /Sprinker: |
$ |
| Other? Explain: |
$ |
| Total Payroll: * |
$ |
| Estimated Annual Gross Sales: * |
$ |
| Limits of General Liability: |
Limits of General Liability: |
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two story |
| Desired Limits of Liability: |
$1,000,000/ $2,000,000
$1,000,000/ $1,000,000
$500,000/ $1,000,000
$500,000/ $500,000 |
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$500 Deductible $1000 other |
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| Umbrella / Excess Limits?: |
$1,000,000 $2,000,000other |
Equipment (send list if availble):
Highest of Value any One Item |
$ Actual Cash Value |
| Cost of all Tools & Equipment: |
$Actual Cash Value |
Property Insurance:
Building Is |
OwnedRentedHome office |
| Contents Replacement Cost: |
$ |
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| Building Replacement Cost: |
$ |
| Square Footage: |
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| Age of Building: |
years |
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| Number of Levels /basement?: |
one story two stories |
| Basement? |
YesNo |
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| Alarms? |
burgular Fire Central Station Alarm? |
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| Building Construction |
Frame BrickSteel |
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Claims Information: Any claims in
past 3 years? Explain |
Yes claims No claims |
Please request Currently-valued
three-year loss runs (claim info)
even if no claims exist- thank you |
Click here for Loss Run Request Letter |
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By acceptance of an insurance policy based on this application, the Insured and/or his representative agrees that the statements in this application are the Insured’s representations, that they shall be deemed material and that the insurance policy is issued in reliance upon the truth of such representations, and that the insurance policy embodies all agreements existing between the Insured and the Company, or any of its agents, relating to this insurance. The Insured acknowledges that this application is a part of the insurance policy.
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Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and (NY: Substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, or VT: in DC, LA, ME and VA, insurance benefits may also be denied). not a market for residential contractors
You're ineligible if performing construction of patios, decks,porches or installation of plumbing systems outside of the scope of use for exterior landscape irrigation (sprinkler system), & retaining wall construction in excess of 10% of total operations or
playground equipment installation
By clicking Submit I agree to these conditions
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