Quote Pest Control Insurance Step 1 of 15 6% QUICK QUOTE REQUEST FROM ATHENA INSURANCE 209 223-1870General Liability and/or Lawn & Landscape General Liability Lawn & Landscape Fumigation and/or Commercial Property Fumigation Commercial Property Commercial Umbrella Umbrella Supplement Bond LOCATIONS - HOW MANY LOCATIONS?Select how many locationsNoneOneTwoMore Section BreakAPPLICANT INFORMATIONThe entire questionnaire must be completed. Read all questions carefully and provide complete answers. Failure to provide complete information will result in delay in consideration of this application. Applicant Name, if Sole Proprietor Company Name or DBA Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFaxCellEmail Enter Email Confirm Email Contact Name Federal ID or Social Security # FEIN if corporation, social security number if sole proprietorWebsite Business Entity TypeSelectSole ProprietorshipPartnershipCorporationLLCOtherDescribe Entity TypeName of Licensed Pest Control Operator/Applicator License # Business License # How long have you owned this company?Please select from list3 years or longerLess than 3 yearsPREVIOUS EMPLOYERThey will not be contactedEmployer Name Address of Previous Employer Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code LOCATIONSLocation 1 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is Location 1 inside city limits? Yes No Is location 1 the primary location? Yes No Location 1 County Name Location 1 PEST CONTROL (COMMERCIAL & RESIDENTIAL) RECEIPTSEstimate your projected 12 / one year policy period gross receipt.sLoc. 1 General Pest Control Receipts Also includes rodents, bees, birds, and exclusion workLoc. 1 Retail Sales of Pest Products Loc. 1 Mosquito Control Receipts Explain control method belowLoc. 1 What Type of Mosquito Control Loc. 1 Wildlife Control Receipts Loc. 1 Wildlife Control MethodWhat procedures, products, methods, & equipment (including the use of firearms) are used in controlling/trapping and in the release/extermination/disposal of animals?Loc. 1 Bed Bugs Methods IPM/Other Loc. 1 Bed Bugs Method Dry Heat Dryheat Loc.1 IPM/Other Receipts Loc. 1 Dry Heat Receipts Loc. 1 TERMITE SERVICESTermite Treatment Receipts Moisture Control Receipts Repairs / Carpentry WDI/WDO INSPECTIONSWDI/WDO Inspections Without Treatment (Wood Destroying Insect/Organism Reports) - Inspections for real estate transactionsand/or refinancing only; DOES NOT include renewal inspections for structures under contract where treatments were performedby you.Average Cost Per Inspection Total Number of Inspection /Year How many free inspections? Total Receipts *cost X number of inspections) Any Free Inspections? Yes No LAWN & ORNAMENTALHerbicide / Weed Control Receipts Right of Way Receipts Lawn Care Receipts Aquatic Spraying Receipts Irrigation Receipts Other receipt for services Describe other services receipts if any Are you now, or have you in the past, been insured under a Wrap-Up or OCIP (Owner Controlled Insurance Program? Yes No Have you ever been named in a claim alleging a construction defect? Yes No You answered yes to Wrap up or construction defect. Please explainLANDSCAPE GARDENINGLAWN & ORNAMENTAL SUPPLEMENT required for any landscaping, lawn sprinkler installation or service, underground work, sidewalk & driveway work, excavating/grading for construction, retail nursery sales and sales of landscaping equipment or chemical productsLandscape Gardening Receipts TREE PRUNING, DUSTING, SPRAYING, REPAIRING, TRIMMING, FUMIGATION ETCLAWN & ORNAMENTAL SUPPLEMENT required for Tree & Shrub PlantingTree Pruning and Dusting receipts FUMIGATIONFumigation (in House /Direct) only Receipts SUBCONTRACTED SERVICESExamples, Fumigation, Janitorial, Pools, Christmas light, etc.Types of Services subcontracted A. Gross Receipts A Cost of Subcontractor A Net Receipts A Type Services B Gross Receipts B. Cost of Subcontractor B Net Receipts B. Types of Services C Gross Receipts C Cost of Subcontractor C Net Receipts C. OTHER TYPES OF SERVICES AND RECEIPTSExamples, Janitorial, Pools, Christmas lights, etc. List other types of services here: Gross Receipts for other services Total Gross Receipts for Location 1 $ Location 2 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is Location 2 inside city limits? Yes No Is location 2 the primary location? Yes No Location 2 County Name Location 2 PEST CONTROL (COMMERCIAL & RESIDENTIAL) RECEIPTSEstimate your projected 12 / one year policy period gross receipt.sLoc. 2 General Pest Control Receipts Also includes rodents, bees, birds, and exclusion workLoc. 2 Retail Sales of Pest Products Loc. 2 Mosquito Control Receipts Loc. 2 What Type of Mosquito Control Loc. 2 Wildlife Control Receipts What procedures, products, methods, & equipment (including the use of firearms) are used in controlling/trapping and in the release/extermination/disposal of animals?Loc 2 Explain Wildlife Proceedures Loc. 2 Bed Bugs Method IPM/Other Loc. 2 Bed Bugs Method Dry Heat Dryheat Loc.2 IPM/Other Receipts Loc. 2 Dry Heat Receipts List all physical address Office name, address Street City, State and Zip CodeLoc. 2 TERMITE SERVICES PEST CONTROL ASSOCIATIONSAre you a member of any pest control Association? Yes No Name of Association EMPLOYEESNumber of employee(s) in each type of service listed belowPest Control Termite Control Non-Contract Inspections Fumigation LICENSESCheck all that apply General Household Pest Commercial Vertebrate Termite WDI/O Fumigation Weed, Herbicide & Lawn Other Describe other Describe other GENERAL INFORMATION1. Does Applicant currently own or operate any other business? Yes No What other business is owned?Describe other business operations2. Has the Applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy? Yes No 3. Has Applicant or any affiliated, telated or predecessor entity or any officer of owner of any of them:a. Ever been convicted of a felony? Yes No Ever defaulted on a labor and material payment bond, performance bond or bid bond or failed to complete or been terminated on any project? Yes No c. Currently been involved in any litigation administration, or arbitration proceeding(s) or been subject to any court or agency order of injunction? Yes No d.Ever been cited by any governmental/regulatory agency or by civil court for violation of any regulations, safety, health, or product label, environmental laws or regulations? Yes No 4.Do you have any knowledge of or reason to expect claims to be filed arising out of pest control Yes No 5.Does Applicant perform building inspections or appraisals, or issue or render services or opinions regarding structural integrity, chemical, air quality or health-related mold issues? Yes No 6.Is pest control operation a full-time business for Applicant? Yes No 6. cont. What is primary occupation? Yes No 7.Does Applicant perform any non-pest control services such as Janitorial, Carpentry, Excavation/Grading, Pools, Electrical, Insulation, Roofing, Plumbing or General Construction? Yes No 7. cont. If yes, please list Do you use subcontractors? Yes No You answers yes to use of subcontactorsIf yes, please be advised that it is your responsibility to obtain certificates of insurance from any subcontractor with whom you do business. The subcontractor’s insurance limits must equal or be higher than yours, and you must be listed as an additional insured under the subcontractor’s policy.TO AVOID POSSIBLE ADDITIONAL PREMIUM AT THE TIME OF AUDIT, LIST ALL PRODUCTS USEDProvide list of products POLICY LIMITS REQUESTEDIf higher limits are desired select higher limits and fill-in the Limits you require. Select Policy Limits$300,000 per Occurrence/$600 Aggregate$500,000 per Occurrence/$1,000,000 Aggregate$1,000,000 per Occurrence/$2,000,000 Aggregate$1,000,000 per Occurrence/$3,000,000 Aggregate$1,000,000 per Occurrence/$4,000,000 Aggregate$1,000,000 per Occurrence/$5,000,000 Aggregate$2,000,000 per Occurrence/$3,000,000 Aggregate$2,000,000 per Occurrence/$4,000,000 Aggregate$2,000,000 per Occurrence/$5,000,000 AggregateHigherWhat limits do you require Deductible $1,000 $2,500 $5,000 $10.000 CLAIMS HISTORYHve you had any claims during the past 3 years? Yes No Policy Year of claim Carrier Name Premium How much was your premium? Date of Loss Amount of Loss Description Are there other claims in the last three years? Yes No Policy Year of Claim Carrier Name Premium Date of Loss Amount of loss Description FUMIGATION SUPPLEMENTAL QUESTIONS PROPERTY SUPPLEMENTAL QUESTIONS LAWN CARE AND LANSCAPING SUPPLEMENTAL UMBRELLA SUPPLEMENT BOND OTHER COVERAGES CONGRATULATIONS! 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