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TheJanitorialStore.com

Insurance Eligibility Form

General Information       (Required *)
Date: * (mm/dd/yyyy)
Business Name: *
Company President/CEO:
Insurance Contact Person: *
Mailing Address/Street:
City:
State:
Zip:
Phone: *
Fax:
E-Mail: *
Est Annual Revenue:
Est Annual Payroll:
# of Employees:
Who are you currently insured with?:
When is your insurance expiration date?:
Any prior coverage declined, cancelled, or non-renewed in the last 3 years?:
YES     NO


Customers/Client Profile

Please give percentages to the following types of customers/clients that you service, for a total of 100%:
Customer Type
%
 Customer Type
%
Office Buildings
Educational Facilities
Manufacturing Plants
Apartment Bldg/Condo
(assn/common areas)
Retail Stores
Airports
Hotels
Museums
Government Facilities
Outdoor Facilities
Residential (private homes)
Restaurants
Other:
Hospitals *
Other:
Nursing Homes *
Other:
Medical Offices *
* If this type of client serviced, do you perform bio-hazard related cleaning or removal?
YES     NO


Types of Services You Provide

Please give percentages to those services below that you provide, for a total of 100%:
Services
%
 Services
%
Gen. Commercial Cleaning ††
Exterior Work Above First Flr.
(windows/power-washing)
Carpet Cleaning Specialist
Snow Removal
Maid/Housekeeping Services
Elevator Maintenance
Pest Control/Extermination
Fire Restoration
Parking Lot Operations
Building Security
Heating/Ventilation/Air Conditioning Service
Other:
Degreasing (restaurant grease traps, Ansul systems, etc.)
Other:
Landscaping (including lawn mowing)
Other:
†† General Commercial Cleaning includes operations such as vacuuming, dusting, wastebasket trash pick-up, floor and rug cleaning, floor waxing (as a part of the above duties), restroom clean-up, etc.


Subcontracted Work
What percentage of your work is subcontracted to others?                %
Describe subbed work:
Do subs provide certificates of insurance?    YES     NO


Any Additional Comments



    



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