Pest Control Questionnarie

Carter & Company, L.L.P.

(If not in Texas, please click here to view a list of states in which we currently have non-resident licenses. If your state is not listed then we would not currently have a market for you.)

Termite & Pest Control Operators
General Liability Application

Note: The applicant's coverage is based upon information given in this Supplemental Questionnaire, and this form is deemed to be a part of the applicant policy. Any person knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading information concerning any fact, thereto commits a fraudulent act, which is a crime under the laws of the United States.

1.	Applicant's Name
	Mailing Address	State Zip
	Location Address
	Telephone Number
	Email Address
	Contact For Inspection or Audit
2.	Desired Effective Date Deductible: Limits:
3.	What are the applicant's total gross receipts? $
Provide Breakdown of receipts in the following categories (Percentages 0% - 100%)
	Termite Treatment % General Pest: %
	Lawn & Ornamental % Fumigation* %
	Inspections - New % Renewals %
	Inspections - Total % Transit Pollution: If desired, please advise number of vehicles owned / operated by applicant
Other (Specify)
*If fumigation is included, describe fumigation process and chemicals used:
4.	Who are applicant's customers? (Provide percentages)
	Commercial %
	Residential %
	Are warnings posted prior to work performed? Yes No
5.	How many employees (excluding owners) are employed?
	Annual Payroll
	What Training is provided for new employees? Are new employees supervised until training is complete? Yes No
6.	Is owner active in business? Yes No Payroll Duties
7.	How long has applicant been in business?
	Has there been any changes in ownership, name or business operations in last three years? Yes No If so, describe
8.	What is applicant's state license number?
9.	Does the applicant engage in retail sale of chemicals? Yes No
	Are chemicals sold and handled as received from the manufacturer? Yes No
	If not, what alterations are made prior to sale? What is total volume in retail sales?
10.	Describe procedures used by applicant to ensure subcontractors used are adequately insured and supply proof of insurance to applicant
11.	Does applicant engage in any business other than pest control? Yes No If yes, describe
12.	How long does applicant maintain records on worked performed?
13.	List chemicals normally used by applicant:
14.	Describe precautions used by applicant to secure chemicals at their business address and at job locations
	Are premises controlled regarding customer access to chemical storage areas? Yes No
	Are chemicals stored in manufacturers containers in separate building? Yes No
	If so, please describe building
15.	Provide any past loss history, including date of occurrence, status of claim, and amount paid or current reserve
16.	Provide any further information you can to assist the company in underwriting your application
17.	Prior insurance carrier
	Receipts Premium:
	Person Filling Application
	Title
	Producer Name: Carter and Company, LLP Agent License # 005983091

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