Janitorial Service Business Insurance Quote Application

Legal Business Name:*
Company name
Company email address*
Contact name
First Last
Business Entity*
Company phone*
Cellphone
Full Address:*
Street Address Address Line 2 City State ZIP Code
Company website
Federal Employer Identification Number (FEIN/EIN):*
Years in business?*
Years in industry experience
Number of owners*
#1 Owner/Officer name
Title First name Last name Percentage of Ownership Payroll (in next 12 Months
#2 Owner/Officer name*
Title First name Last name Percentage of Ownership Payroll (in next 12 Months
#2 Owner/Officer name*
Title First name Last name Percentage of Ownership Payroll (in next 12 Months
#3 Owner/Officer name*
Title First name Last name Percentage of Ownership Payroll (in next 12 Months
#3 Owner/Officer name*
Title First name Last name Percentage of Ownership Payroll (in next 12 Months
#3 Owner/Officer name*
Title First name Last name Percentage of Ownership Payroll (in next 12 Months
Type of coverage desired*
- Select All
- General liability
- Commercial auto
- Inland marine
- Commercial property
- Professional liability
- Bond
- workers' compensation

Do you perform work on residential projects valued over $2 million ?*
Please provide details*
Do you require subcontractors to have a written contract, provide certificates of insurance showing limits of liability equal to or greater than those on your policy ?*
Please provide details*
Any exterior work exceeding three (3) stories in height ?*
Please provide details*
Work on condominiums, townhouses, or Tract Developments with more than 25 units ?*
Please provide details*
Any work with student housing, senior housing, assisted living facilities, or retirement homes involving more than one (1) individual unit within the development ?*
Please provide details
Work on slopes greater than 15 degrees or retaining walls higher than 6 feet ?*
Please provide details*
Any installation or work with wood, coal, or waste oil burning stoves ?*
Please provide details*
Any installation of fire extinguishing systems or monitoring of alarm systems ?*
Please provide details*
Any work on railroads, traffic lights, airports, recreation facilities, petroleum plants, chemical facilities, elevators, escalators, retrofitting, or foundation repair/stabilization ?*
Please provide details*
Any swimming pool installation, work with fiber optics, or tunneling operations ?*
Please provide details*
Have you filed bankruptcy in the past 3 years?*
Please provide details*
During the past three years has any company ever cancelled, non renewed, declined, or refused to issue similar insurance ?*
Please provide details*
Have you had any general liability insurance claims in the past 3 years ?*
Please provide details*
Do you have knowledge of any event that may result in a general liability insurance claim ?*
Please provide details*

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