CIU Commercial Insurance Underwriters, Inc.
A Surplus Lines Agency
www.ciusgf.com
901 E. Saint Louis St. #205
Springfield, MO. 65806-2537

Janitorial Program Supplemental Application

(Complete in addition to ACORD General Liability Application)

Applicant's Name

Agency Name

Address

Agent

 

Address

Location

 

 

Email

Web Site Address

Phone

 

PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant

 

Applicant Is: Individual  Corporation   Partnership    Joint Venture   Limited Liability Company   Other 

 

1. How long have you been in business? Currently: Full-time     Part-time

2. Mix of business: Commercial % Industrial % Residential %

3. Property Damage Extension (see limit options on back): $Occurrence

(coverage option selected, if limits are indicated)      $Aggregate

4.

Employee Data

Number

Annual Payroll

 

Owner(s) only

     

$      

 

Employees excl. clerical: Full Time

     

$      

 

Part Time

     

$     

 

 

 

 

 

Leased or Subcontracted

Number

Annual Cost

 

Leased employees

    

$    

 

Independent Contractors*

     

$    

*Do independents provide you with certificates of insurance?.............................................................

5. Indicate annual sales for each of the following industries serviced:

Operations for

Annual Sales

Operations for

Annual Sales

Aircraft

$   

Offices

$ 

Apartments

$    

Off-shore Oil Rigs

$ 

Construction Make-Ready

$    

Private Residences

$ 

Convenience Stores, Grocery Stores and Supermarkets

$

Retail Stores

$

Convention Halls

$   

Schools/Colleges/Universities

$

Crime Scene Cleanup

$    

Shopping Centers & Malls

$ 

Department/Discount Stores

$    

Sports Complexes

$ 

Hospitals/Convalescent Homes

$  

Transportation Terminals

$ 

Hotels

$ 

Theaters

$

Industrial

$ 

 

$

Other (describe)     

$

Total Annual Sales

$

6. Type of Operations Performed (show sales figures for operations):

Operation

Payroll

Sales

Carpentry

$     

$     

Carpet/Upholstery Cleaning

$     

$     

Construction Cleanup: Interior Exterior

$    

$     

Consulting

$   

$     

Equipment Rental

$      

$    

Fire/Water Restoration

$    

$ 

Floor Stripping/Waxing

$     

$    

Janitorial—General Services

$  

$    

Janitorial Supply Retail/Wholesale

$    

$    

Landscaping/Plant or Shrub Servicing

$   

$   

Machinery/Equip. Clean/Degreasing

$   

$    

Mold or Spore Remediation

$    

$     

Painting

$  

$

Pressure Washing

$   

$  

Recycling

$ 

$

Sandblasting

$  

$ 

Security

$

$

Snowplowing

$ 

$

Restaurant Hood Cleaning

$

$  

Window/Screen/Skylight Cleaning

$ 

$ 

Other (describe) 

$ 

$ 

7. Window Cleaning:

Maximum number of stories:

Scaffolding/rigging, if any: Rented Owned

8. Please provide a brief description of any hazardous waste handled, storage of combustible material, and

      recyclables handled:

9. Are your employees bonded?.........................................................................................................

If yes, effective date of coverage:

10. Do you have other business ventures for which coverage is not requested?.................................

If yes, explain and advise where insured:

   


FRAUD WARNING:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

APPLICABLE IN THE STATE OF NEW YORK:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

APPLICANT’S NAME AND TITLE:

APPLICANT’S SIGNATURE: __________________________________________________________________ Date:                     

(Must be signed by an owner, partner or executive officer)

PRODUCER’S SIGNATURE: _______________________________________________________ DATE:                     

Before You Submit To Us, Make Sure You Fill in the RED Areas.  We Also Recommend Printing a Copy!!

TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
1.  Please select your Personal Lines Account Executive:

2.  Hit this Submit button.