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Arborist Supplemental Application


Payroll & Receipts History

Expiring Year Payroll ________________________Gross Receipts ______________

2nd Prior Year Payroll ________________________Gross Receipts ______________

3rd Prior Year Payroll ________________________ Gross Receipts ______________

4th Prior Year Payroll ________________________ Gross Receipts ______________

The undersigned applicant warrants the above statements and particulars,

together with any attached or appended documents or materials (this application),

are true and complete and do not misrepresent, misstate or omit any material

facts. Furthermore, the applicant authorizes the Company, as administrative and

service anger, to make any investigation and inquiry in connection with the

Application as it may deem necessary.

The applicant agrees to notify the Company of any material changes in the

answers to the questions on this application which may arise, prior to the date of

the policy issued pursuant to the is application and the applicant understands that

any outstanding quotations may be modified or withdrawn based up such changes

at the sole discretion of the Company.

Notwithstanding any of the foregoing, the Applicant understand that the Company

is not obligated nor under any duty to issue a policy of insurance based upon this

information.

Owner’s Signature __________________________________________________

Print Name ________________________________________________________

Date _____________________________________________________________

You will be contacted by a member of our Customer Service Team. They may

request additional information such as the following:

A COPY OF YOUR SUBCONTRACTOR’S AGREEMENT

SALES CONTRACT

LOSS RUNS FOR THE PAST FIVE YEARS

Completed applications may be faxed to 888-907-5998



Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Contact
Optional
Company Name
Required
Fax #
Required
Website Address
Optional
Federal Identification Number
Optional
Business Type
Optional
Effective Date
Optional
/ /
Year Business Established
Optional
Prior Insurance
Optional
Primary Business Operations in Detail
Optional
Does Any Named Insured have another separate General Liability Policy
Optional
Any Discontinued Operations by any Named Insured
Optional
Any Out of State operations? If so, please list
Optional
Percentage of Commercial? Residential?
Optional
What are commercial operations, please describe
Optional
Tree Pruning/Removing/Fertilization/StumpGrinding %
Optional
Landscape/Lawn Maintenance %
Optional
Describe Any Specialty operations/products
Optional
License (State, Number)
Optional
Qualifier of License?
Optional
Description of Work Performed:
Optional
Pesticide or Herbicide Application%
Optional
Utility Line Clearance%
Optional
Snow Plowing: Commercial% Residential%
Optional
Other Operations
Optional
Member of TCIA? ISA? Local ISA Chapter? Other
Optional
TCIA Accreditation?
Optional
Number of Certified Arborist's on Staff?
Optional
Number of CTSP's on Staff?
Optional
Estimated Payrolls of Employees in Field for Upcoming Year?
Optional
Sales Payroll for Upcoming Year?
Optional
Clerical Payroll for Upcoming Year?
Optional
#of Corporate Officers In Field Working?
Optional
#of Corporate Officers or Managers in Office for Upcoming Year?
Optional
Subcontracted Work Estimated for Next Year?
Optional
Estimated Sales for Next Year?
Optional
Explain any crane operations
Optional
Any work above 90 feet? Maximum Height?
Optional
Written Safety Program?
Optional
Are Regular Safety Meetings Conducted? How Often?
Optional
Is Personal Protective Equipment Provided and what kind?
Optional
Drug Testing?
Optional
Is There a Return to Work Program?
Optional
Is there an incentive based safety program?
Optional
Are certificates of Insurance obtained from subcontractors?
Optional
Are employees trained in electrical Hazard awareness?
Optional
Is there a schedule maintenance program for all vehicles?
Optional
Is their a maintenance ^ repair log maintained for these vehciles?
Optional
Is there a personal use policy for company vehciles?
Optional
Are MVR's obtained for each driver?
Optional
Does Management review MVR's?
Optional
Is disciplinary action taken for poor drivers or accidents?
Optional
Are road tests given prior to operating company vehicles?
Optional
Are driver trained in defensive driver techniques?
Optional
Are employees instructed in accident reporting procedures?
Optional
Building Protection : Check All that apply Fire Extinguishers Central Station Alarm Sprinklers
Optional
Is the yard fenced and well lit?
Optional
Are tools and equipment locked up overnight?
Optional
Do you rent/lease/borrow equipment from others?
Optional
With Operators? Without Operators?
Optional
Describe the typ of equipment rented/leased/borrowed?
Optional
Do You rent/lease/loan equipment to others?
Optional
With Operators? Without Operators?
Optional
Is there a rental lease contract?
Optional
Does your compnay apply pesticides/herbicides? If No, do not complete remainder of this section
Optional
Are you licensed to apply pesticides/herbicides in your state?
Optional
Is certification required to apply pesticides/herbicides?
Optional
How are pesticides/herbicides applied?
Optional
How are pesticides/herbicides stored on premises?
Optional
What is the quantity stored on premises?
Optional
Has the company ever had a pollution claim?
Optional
Please list pesticides/herbicides used
Optional
Please list the last 10 jobs completed
Required
Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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