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General Liability Application

Proposed Effective Date: *
Applicant's Name: *
Office Contact:
Mailing Address 1:    
Mailing Address 2:    
Business Location 1:    
Business Location 2:    
Phone Number:    
Corporation    Sole Proprietor    Partnership
PCO License Number: FEIN:
Year Business Started: Years in Industry:
Number of Employees:    
Liability Limits desired: $ per occurrence,  $ general aggregate
Anticipated total gross receipts for the next policy period, from all sources:  $
Pest Control (GHP):    
Fumigation Treatment:: Fume Sub-Out (Net):
Termite: Sales (New): Termite: Renewals:
Termite: WDI Inspections:    
Bed Bugs: Heat Treatment::
Lawn & Ornamental - Sales: L & O Payroll:
Landscape Mntc - Sales: Mntc Payroll:
Do you belong to any Pest Control Associations: 

Current Year Company:  Losses:
1st Prior Year Company:  Losses:
2nd Prior Year Company:  Losses:
3rd Prior Year Company:  Losses:
In order to apply for rate experience discounts, please list insurance carriers for the past four (4) years.