Residential Cleaning Services

General Information

Date Form Completed

Person Completing Form

Franchise Affiliation, if any

Business Name (incl Corp and T/A names)

Contact Person

Title

Mailing Address

Location Address

Phone

Fax

Entity Type (Corp, Sole Prop, LLC, etc)

Date business started

Federal ID #

Current Insurance Carrier(s)

How Long with Carrier(s)?

Coverage Expiration Date

Do all policies expire on same date? If not, provide all dates

Please list all states in which you do business

# of Clients/Contracts

* PLEASE ATTACH COPIES OF YOUR CURRENT POLICY DECLARATIONS PAGES FOR MOST ACCURATE QUOTE *

Policy Limits | PROPERTY

Building

► Office Contents Replacement Value

Business Income (if over $50,000)

Valuable Papers (if over $25,000)

Accounts Receivable (if over $25,000)

Exterior Sign

Building Glass (measurements)

Other Property (Describe / Value)

Unscheduled Mobile Equipment Limit (max $1,000 per item)

Scheduled Mobile Equipment (for individual items exceeding $1,000): PLEASE ATTACH SCHEDULE

► Contents may include, but is not limited to: Leasehold Improvements, Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, and Property of Others in Your Care. Please consult your lease requirements when choosing the coverage and limits for this location.

Policy Limits | CRIME

Employee Dishonesty (if over $25,000)

Money & Securities (if over $10,000)

401(k) Plan? Name of Plan

Policy Limits | GENERAL LIABILITY

General Aggregate Limit

Each Occurrence Limit

Fire Legal Liability Limit

Medical Payments Limit

Property Damage Deductible (if over $500)

Employee Benefits Liability (if group benefits provided)

WORKERS COMPENSATION | OWNERS | List below all owners of the business, whether active or inactive.

Owner/Officer Name

Title

% of Ownership

Duties (or indicate if inactive)

Annual Payroll/Salary

Include or Exclude?

WORKERS COMPENSATION | List below payroll for all employees EXCEPT OWNERS

Residential Cleaning – Labor

Estimated Annual Payroll (do not include owners here)

# FT Employees

# PT Employees

State

Employers Liability Limit (if other than 100,000 / 500,000 / 100,000)

Office – Inside

Estimated Annual Payroll (do not include owners here)

# FT Employees

# PT Employees

State

Employers Liability Limit (if other than 100,000 / 500,000 / 100,000)

Sales – Outside

Estimated Annual Payroll (do not include owners here)

# FT Employees

# PT Employees

State

Employers Liability Limit (if other than 100,000 / 500,000 / 100,000)

Policy Limits – AUTOMOBILE

Auto Liability (Combined Single or Split Limits)

Uninsured / Underinsured Motorist Limit(s)

Medical Payments

Personal Injury Protection

Comp Deductible

Collision Deductible

Towing & Labor (for private passenger vehicles)

Rental Reimbursement

If any owners / key employers have their personal vehicles on policy, please give their names and names of their spouses

Policy Limits – UMBRELLA

Umbrella Liability Limit (if other than $1,000,000)

PROPERTY – Underwriting Questions

Type of building you occupy (office, retail strip mall, industrial, etc.)

Owner or Tenant?

# of Stories

Construction (Frame, Masonry, Noncombustible, Fire Resistive, etc)

Sq Ftg You Occupy

Approx Yr Built

If bldg over 30 yrs old, Year(s) Updated for Wiring, Heating, Plumbing, Roof

GENERAL LIABILITY – Underwriting Questions

Estimated Annual Receipts

Annual Receipts for Prior Year

Annual Amt Paid to Subcontractors

Do Subs provide Certificates with limits at least equal to yours?

Yes

Is a formal safety program in operation?

Yes

Any exposure to flammables, explosives, chemicals?

Yes

Do you install, service, or demonstrate products?

Yes

Do you provide guarantee, warranty, or hold harmless?

Yes

Any exposure to radioactive / nuclear materials?

Yes

Any operations involving storing, treating, discharging, applying, disposing, or transporting of hazardous material?

Yes

Do you lease employees to or from other employers?

Yes

Have any crimes occurred or been attempted on your premises within the last three years?

Yes

Is there a formal, written safety and security policy in effect for your location?

Yes

Does your promotional literature make any representations about the safety or security of the premises?

Yes

Do you install, service, or demonstrate products?

Yes

Explain all YES answers below

AUTOMOBILE – Underwriting Questions

Do over 50% of employees use their autos in the business?

Yes

Is there a vehicle maintenance program in operation?

Yes

Are any vehicles leased to others?

Yes

Any vehicles customized, altered or have special equipment?

Yes

Do operations involve transporting hazardous material?

Yes

Any vehicles used by family members? If so, identify below.

Yes

Do you obtain motor vehicle records for new drivers?

Yes

Do you have a specific driver recruiting method?

Yes

Any drivers with moving traffic violations?

Yes

Explain all YES answers below

WORKERS COMPENSATION – Underwriting Questions

Do you have an Experience Modification Factor?

Yes

If so, what is that factor and when is it effective?

Any work performed underground or above 15 feet?

Yes

Are you engaged in any other type of business?

Yes

Any group transportation provided?

Yes

Any seasonal employees?

Yes

Do employees travel out of state?

Yes

Are physicals required after offers of employment are made?

Yes

Are employee health plans provided?

Yes

Do any employees predominantly work at home?

Yes

Any prior coverage declined, cancelled or non‐renewed in the last 3 years?

Yes

Explain all YES answers below

UMBRELLA – Underwriting Questions

Is bridge, dam, or marine work performed?

Yes

Is contract or agreement made with customer? If so, attach copy

Yes

Do you own, rent, or otherwise use cranes or scaffolds?

Yes

Explain all YES answers below

ADDITIONAL REMARKS

VEHICLE SCHEDULE – Please complete the below or attach a separate schedule of your own

Year

Make / Model

Vehicle ID (Serial Number)

Original Cost New

Garaging City, State

** Titled/Leased in business name?

Yes

** For vehicles not titled/leased in the business name, please indicate the name of the titled owner or lessee for each vehicle:

DRIVER SCHEDULE – Please complete the below or attach a separate schedule of your own

Driver Name (as it appears on license)

Drivers License Number

State

Date of Birth

GENERAL UNDERWRITING QUESTIONS

Do employees work in pairs?

Yes

Are employees supervised on the job?

Yes

Are single‐person jobs limited to experienced staff?

Yes

Are periodic unannounced job site management checks performed?

Yes

Are written applications completed by all prospective employees?

Yes

Are references checked?

Yes

Does employment application ask about prior criminal acts?

Yes

Are criminal background checks performed on all employees?

Yes

Any bid or performance bonding needed?

Yes

DESCRIBE BELOW ANY LOSS CONTROL & SAFETY MEASURES IN PLACE TO AVOID EMPLOYEE INJURY, AUTO ACCIDENTS, AND CUSTOMER PROPERTY DAMAGE (driver training, loss prevention meetings, new hire training, etc.)

OTHER COVERAGE TO CONSIDER – Please type any comments or requests below

Do you need coverage for trips or work outside the United States?

Would you like an optional Umbrella Quote?

Would you like an Employee Benefits Quote (health, life, disability, long‐term care)?

Would you like an Employment Practices Liability Quote?

Interested in any other coverage not shown above?

Describe Other Coverage requests here:

PLEASE CONTACT YOUR CURRENT AGENT OR INSURANCE COMPANY FOR A CURRENTLY‐VALUED LISTING OF YOUR CLAIMS HISTORY (“LOSS RUNS”) FOR THE PAST 3 YEARS.

Professional Cleaning – Residential

General Information

Policy Limits | PROPERTY

Policy Limits | CRIME

Policy Limits | GENERAL LIABILITY

WORKERS COMPENSATION | OWNERS | List below all owners of the business, whether active or inactive.

WORKERS COMPENSATION | List below payroll for all employees EXCEPT OWNERS

Residential Cleaning – Labor

Office – Inside

Sales – Outside

Policy Limits – AUTOMOBILE

Policy Limits – UMBRELLA

PROPERTY – Underwriting Questions

GENERAL LIABILITY – Underwriting Questions

AUTOMOBILE – Underwriting Questions

WORKERS COMPENSATION – Underwriting Questions

UMBRELLA – Underwriting Questions

VEHICLE SCHEDULE – Please complete the below or attach a separate schedule of your own

DRIVER SCHEDULE – Please complete the below or attach a separate schedule of your own

GENERAL UNDERWRITING QUESTIONS

OTHER COVERAGE TO CONSIDER – Please type any comments or requests below

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