Liability Application For Pest Control Program
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4LIABILITY APPLICATION FOR PEST CONTROL PROGRAM
1.
NAME: _______________________________________________________________________________________
(COMPLETE NAME AS IT SHOULD APPEAR ON THE POLICY, INCLUDING INC., CORP., LTD., ETC.)
2.
Physical Address: _______________________________________________________________________________
NO.
STREET
CITY
COUNTY
STATE
ZIP
3.
Mailing Address: _______________________________________________________________________________
NO.
STREET
CITY
COUNTY
STATE
ZIP
4.
Policy proposed effective date __________________ to ________________
(12:01 AM Standard Time at the address above)
5.
Check limit of liability desired:
$300,000
$500,000
$1,000,000
Excess
6.
Phone: _________________________________________ Fax: _________________________________________
7.
Email: _________________________________________ Website: ______________________________________
8.
How did you hear about us?
Web surfing
Ad in which publication: _____________
Other: ___________
9.
Date established: __________
Corporation
Partnership
Individual
Other: __________________
10.
Federal ID Number: ______________________________ License Number: _______________________________
11.
Principal: _______________________________________ Title: ________________________________________
12.
Person to contact for Audit: ________________________ Title: ________________________________________
13.
Total number of employees: ________
Clerical: ________
Techs: ________
Outside Sales: _________
14.
Describe training program now in force for non-certified employees:
15.
Does training program include a minimum of 4 weeks of on-the-job training with a supervisor?
Yes
No
16.
Do you mix chemicals of others and place your labels on them?
Yes
No If yes, please give details:
17.
What instructions or warnings do you provide at the time of application?
18.
Do you make follow-up visits after a pest treatment?
Yes
No If yes, how long after treatment? __________
19.
Do you make follow-up phone calls after a pest treatment?
Yes
No If yes, how long after treatment? _____
20.
Do you provide pre-treatments to new structures?
Yes
No Chemical(s) used for pre-treatments:
______________________________________________________________________________________________
21.
Are technicians specially trained for pre-treatment work?
Yes
No
22.
Are label directions for application and chemical amount strictly followed?
Yes
No
23.
Do you provide WDO/WDI inspections?
Yes
No
a. Average amount of time spent performing a pest inspection:
____________ hours
__________ minutes
b. Number of inspections done annually for real estate closings: _________________________________________
24.
List your (3) largest clients: 1 ______________________________________________________________________
2 ______________________________________________________________________
3 ______________________________________________________________________
07/11 ed.
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