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LANDSCAPING QUOTE
Applicant's Name:
Mailing Address:
City  State     Zip
Phone:      Fax: 		PROPOSED EFFECTIVE DATE:
From     To

Email:
 Applicant is:   Individual Corporation Partnership Joint Venture
                           Limited Liability Company Other (Specify)
LIMITS OF LIABILITY REQUESTED
  General Aggregate $  
  Products & Completed Operations Aggregate $  
  Personal & Advertising Injury $  
  Each Occurrence $  
  Fire Damage (any one fire) $  
  Medical Expense (any one person) $  
  Property Damage Extension (CCC)
Occurrence  
 $
Aggregate  
 $
  Other $  
  Other $  
  Deductible ($500 minimum) $
 
LOCATION OF OPERATIONS
Street Address and City State
 1.   Same as mailing address
 2.
 3.
    
1. How long has applicant been in business?  years       Full-time       Part-time        
2. Does applicant use pesticides or herbicides?       Yes      No
If yes, are they EPA approved       Yes       No
     
How are employees trained in handling:
3. Does applicant subcontract work?      Yes      No
If yes: Annual subcontract cost: $
Type of work subcontracted:
Are Certificates of Insurance obtained?       Yes      No
DESCRIPTION OF OPERATIONS

Operation

 Payroll

 

 Receipts

 
Landscaping

 

$

Not Applicable
Lawn Servicing (mowing, fertilizing, etc.)

 

$

Not Applicable
Snowplowing
Residential
 
Commercial - Retail
 
Commercial - Other
 
Streets and roads

$

$

$

$

$

$

$

$

Tree work

 

  

$

Not Applicable
Fumigation, crop dusting or aerial spraying

 

$

Not Applicable
Highway or utility right-of-way maintenance

 

$

Not Applicable
Sales of commercial fruit trees and/or seeds

 

Not Applicable

$

Other - Please describe

 

  

$

$

Total Payroll (excluding snowplowing) 

$

Not Applicable
EMPLOYEE DATA
Category

 

 Number

 

   During the past three years has any company ever canceled, declined or refused to issue similar insurance to the applicant?  (Not applicable in Missouri)
 Yes    No

If yes, please explain:

 
Owner(s) only

 
  Other than clerical:
  Full-time

 
  Part-time

 
  Leased

 

Total  
   
PRIOR INSURANCE HISTORY     See loss run attached

 

Year

Company

Policy No.

Premium

Paid Losses

Reserved Losses

Loss Description

ADDITIONAL INSURED INFORMATION
Name
Address
  
  
  

 

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