Insurance Custodial Services Application

INSURANCE CUSTODIAL SERVICES APPLICATION

Applicant Name:   DBA:

Entity and Contact Information

Sole Proprietor    Partnership    Limited Liability Company (LLC)    Corporation    Other:

Business / Operational Information

Location(s) Where Services Are Performed:

Routine Cleaning    Floor Care (polish/strip/wax)    Carpet Cleaning    Window Cleaning    Pressure Washing
Medical/Healthcare Facility Cleaning    Disinfection/Sanitization    Hazardous Material Handling    Commercial Kitchen Cleaning

Loss History and Claims

Have you had any claims, suits, or incidents in the past five (5) years that could give rise to a claim? Yes No

Requested Policy Details

General Liability    Property    Workers' Compensation    Professional Liability / Errors & Omissions    Commercial Auto

Coverage Acknowledgements and Exclusions

The undersigned acknowledges that the policy, if issued, will include customary exclusions. The applicant confirms awareness and acceptance of the following typical exclusions unless specifically endorsed:

• Pollutant or contamination liability, except as may be specifically endorsed;
• Intentional acts, willful misconduct, and criminal acts of insured persons;
• Contractual liabilities except those assumed under insured agreements specifically covered;
• Liability arising from professional services not specifically endorsed under professional liability coverage;
• Employee dishonesty, theft, and fidelity loss, unless a separate bond or fidelity policy is purchased.

Applicant acknowledges review of exclusions and requests the insurer to consider endorsements where available: Request endorsements    Do not request endorsements

Beneficiary / Payee Information

Beneficiary Name:    Relationship:

Representations, Consent and Certification

By signing below, the applicant certifies that all statements and information contained in this application are true, complete, and accurate to the best of the applicant's knowledge. The applicant understands that any material misstatement, omission or concealment of fact may result in denial of coverage or rescission of the policy.

The applicant authorizes the insurer and its representatives to obtain loss history, claims information, underwriting reports, and to make any inquiries necessary to evaluate the application, including but not limited to background checks, credit checks where permitted by law, and verification of licenses, bonds, and certifications.

Fraud Notice: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application containing false information may be subject to civil or criminal penalties as allowed by law.

Premium Terms: Coverage is subject to payment of premium when due, audit and adjustment of premium based upon actual exposures, and the terms, conditions and limitations of the policy issued. Coverage may be cancelled or nonrenewed in accordance with the policy terms.

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