A. Is applicant licensed? Yes     No    License number      Years in Business

 B. Estimated annual sales  $

 C. Sales from termite inspections without termite treatment $ (this category does not include sales for renewal
     inspections where a previous treatment for termites had been done). Sales from termite treatment $

 D. Number of employees   Does applicant have a training program for his employees? Yes     No   
      If so, describe:
     

 E. Does applicant have Workers' Compensation coverage in force? Yes     No 

 F. Does applicant lease employees? Yes     No

 G. Does applicant do any tenting?  Yes     No    What percentage of sales? %

 I. Does applicant do any random testing? Yes   No    If so, sales  
Who does the analysis?

 J. Does risk store petroleum products in underground tanks, L.P.G., flammable liquids, ammunition or explosives on the premises?   Yes   No   
If so, type and quantity stored

 K. Does risk lend, lease, or rent any equipment to others? Yes   No
      If so, state the type of equipment involved and the sales derived therefrom.

 L. Does applicant subcontract work?   Yes   No   If so, state type

 M. During the past three years has any company ever cancelled, declined or refused to issue similar insurance to the applicant?
      Yes   No    If so, explain