Insurance Pest Control Application

INSURANCE PEST CONTROL APPLICATION

Applicant Name:

Entity and Contact Information

Entity Type: Individual Sole Proprietor Partnership Corporation LLC Other

If Other, describe:

Policy Details Requested

Coverage Type (select all that apply): Commercial General Liability Professional Liability (E&O) Property Damage Pollution/Pesticide Liability Workers' Compensation Automobile Liability Product Liability

Coverages and Endorsements

Yes — add additional insured(s) by endorsement

Exclusions and Acknowledgements

The policy applied for will contain standard exclusions including, without limitation: (a) losses arising from intentional wrongful acts or fraud by the insured; (b) pre-existing infestations and damage known to the insured prior to the inception of coverage; (c) damage resulting from defective workmanship unrelated to covered occurrences; (d) bodily injury or property damage caused by intentional release of prohibited substances; (e) pollution and pesticide contamination except where specific pesticide/pollution liability coverage is purchased and endorsed. Applicant acknowledges that pesticide applications may give rise to third‑party claims and that such claims may be excluded unless pollution/pesticide liability coverage is included and endorsed.

By checking this box, Applicant certifies that Applicant has read and understands the exclusions described above and accepts that coverage is limited as indicated.

Claims and Loss History

Have you had any claims, suits, or losses arising from pest control operations in the past five (5) years? Yes No

Largest loss amount in past five years:

Operations, Chemicals and Safety

Number of full-time technicians:

All applicators are licensed where required Written safety and pesticide handling program in place

Beneficiary / Payee for Policy Proceeds

Primary Payee Name:

Attachments Checklist

Please attach copies of the following as applicable: Proof of license/certification Material Safety Data Sheets (MSDS) for chemicals used Equipment and vehicle list with VINs Current vehicle insurance declarations (if vehicles used) Prior policy declarations (most recent 3 years if available)

Declarations and Certification

I hereby declare that the statements made in this application are true, complete and correctly recorded to the best of my knowledge. I understand that the information contained in this application shall form the basis of any policy issued and that any material misrepresentation, omission, concealment, or incorrect statement may void coverage in whole or in part and may be a basis for denial of claims. I authorize the insurer to obtain and verify information from any source, including inspection of premises and claims history, and to provide underwriting information to other insurers as permitted by law. I understand that acceptance of this application and issuance of a policy is subject to underwriting review and that coverage, limits, endorsements and premium are subject to the insurer's approval.

Fraud Warning: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing false or misleading information may be subject to civil or criminal penalties under applicable law.

By checking this box and signing below, Applicant certifies under penalty of perjury that the information provided in this application and any attachments is true and correct, and authorizes the insurer to rely on it for underwriting and binding coverage.

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