Cleaning Service Program Quote - Moody Insurance Worldwide

General Information

Date Form Completed

Person Completing Form

Franchise Affiliation, if any

Business Name (incl Corp and T/A names)

Contact Person

Title

Mailing Address

Location Address

Phone

Fax

Email

Entity Type (Corp, Sole Prop, LLC, etc)

Date business started

Federal ID #

Current Insurance Carrier(s)

How Long with Carrier(s)?

Coverage Expiration Date

Do all policies expire on same date? If not, provide all dates

Please list all states in which you do business

# of Clients/Contracts

* PLEASE ATTACH COPIES OF YOUR CURRENT POLICY DECLARATIONS PAGES FOR MOST ACCURATE QUOTE *

Policy Limits | PROPERTY

Building

► Office Contents Replacement Value

Business Income (if over $50,000)

Valuable Papers (if over $25,000)

Accounts Receivable (if over $25,000)

Exterior Sign

Building Glass (measurements)

Other Property (Describe / Value)

Unscheduled Mobile Equipment Limit (max $1,000 per item)

Scheduled Mobile Equipment (for individual items exceeding $1,000): PLEASE ATTACH SCHEDULE

► Contents may include, but is not limited to: Leasehold Improvements, Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, and Property of Others in Your Care. Please consult your lease requirements when choosing the coverage and limits for this location.

Policy Limits | CRIME

Employee Dishonesty (if over $25,000)

Money & Securities (if over $10,000)

401(k) Plan? Name of Plan

Policy Limits | GENERAL LIABILITY

General Aggregate Limit

Each Occurrence Limit

Fire Legal Liability Limit

Medical Payments Limit

Property Damage Deductible (if over $500)

Employee Benefits Liability (if group benefits provided)

WORKERS COMPENSATION | OWNERS | List below all owners of the business, whether active or inactive.

Owner/Officer Name

Title

% of Ownership

Duties (or indicate if inactive)

Annual Payroll/Salary

Include or Exclude?

WORKERS COMPENSATION | List below payroll for all employees EXCEPT OWNERS

Janitorial Services – Labor

Estimated Annual Payroll (do not include owners here)

# FT Employees

# PT Employees

State

Employers Liability Limit (if other than 100,000 / 500,000 / 100,000)

Office – Inside

Estimated Annual Payroll (do not include owners here)

# FT Employees

# PT Employees

State

Employers Liability Limit (if other than 100,000 / 500,000 / 100,000)

Sales – Outside

Estimated Annual Payroll (do not include owners here)

# FT Employees

# PT Employees

State

Employers Liability Limit (if other than 100,000 / 500,000 / 100,000)

Policy Limits – AUTOMOBILE

Auto Liability (Combined Single or Split Limits)

Uninsured / Underinsured Motorist Limit(s)

Medical Payments

Personal Injury Protection

Comp Deductible

Collision Deductible

Towing & Labor (for private passenger vehicles)

Rental Reimbursement

If any owners / key employers have their personal vehicles on policy, please give their names and names of their spouses

Policy Limits – UMBRELLA

Umbrella Liability Limit (if other than $1,000,000)

PROPERTY – Underwriting Questions

Type of building you occupy (office, retail strip mall, industrial, etc.)

Owner or Tenant?

# of Stories

Construction (Frame, Masonry, Noncombustible, Fire Resistive, etc)

Sq Ftg You Occupy

Approx Yr Built

If bldg over 30 yrs old, Year(s) Updated for Wiring, Heating, Plumbing, Roof

GENERAL LIABILITY – Underwriting Questions

Estimated Annual Receipts

Annual Receipts for Prior Year

Annual Amt Paid to Subcontractors

Do Subs provide Certificates with limits at least equal to yours?

Yes
No

Is a formal safety program in operation?

Yes
No

Any exposure to flammables, explosives, chemicals?

Yes
No

Do you install, service, or demonstrate products?

Yes
No

Do you provide guarantee, warranty, or hold harmless?

Yes
No

Any exposure to radioactive / nuclear materials?

Yes
No

Any operations involving storing, treating, discharging, applying, disposing, or transporting of hazardous material?

Yes
No

Do you lease employees to or from other employers?

Yes
No

Have any crimes occurred or been attempted on your premises within the last three years?

Yes
No

Is there a formal, written safety and security policy in effect for your location?

Yes
No

Does your promotional literature make any representations about the safety or security of the premises?

Yes
No

Do you install, service, or demonstrate products?

Yes
No

Explain all YES answers below

AUTOMOBILE – Underwriting Questions

Do over 50% of employees use their autos in the business?

Yes
No

Is there a vehicle maintenance program in operation?

Yes
No

Are any vehicles leased to others?

Yes
No

Any vehicles customized, altered or have special equipment?

Yes
No

Do operations involve transporting hazardous material?

Yes
No

Any vehicles used by family members? If so, identify below.

Yes
No

Do you obtain motor vehicle records for new drivers?

Yes
No

Do you have a specific driver recruiting method?

Yes
No

Any drivers with moving traffic violations?

Yes
No

Explain all YES answers below

WORKERS COMPENSATION – Underwriting Questions

Do you have an Experience Modification Factor?

Yes
No

If so, what is that factor and when is it effective?

Any work performed underground or above 15 feet?

Yes
No

Are you engaged in any other type of business?

Yes
No

Any group transportation provided?

Yes
No

Any seasonal employees?

Yes
No

Do employees travel out of state?

Yes
No

Are physicals required after offers of employment are made?

Yes
No

Are employee health plans provided?

Yes
No

Do any employees predominantly work at home?

Yes
No

Any prior coverage declined, cancelled or non‐renewed in the last 3 years?

Yes
No

Explain all YES answers below

UMBRELLA – Underwriting Questions

Is bridge, dam, or marine work performed?

Yes
No

Is contract or agreement made with customer? If so, attach copy

Yes
No

Do you own, rent, or otherwise use cranes or scaffolds?

Yes
No

Explain all YES answers below

ADDITIONAL REMARKS

VEHICLE SCHEDULE – Please complete the below or attach a separate schedule of your own

Year

Make / Model

Vehicle ID (Serial Number)

Original Cost New

Garaging City, State

** Titled/Leased in business name?

Yes
No

** For vehicles not titled/leased in the business name, please indicate the name of the titled owner or lessee for each vehicle:

DRIVER SCHEDULE – Please complete the below or attach a separate schedule of your own

Driver Name (as it appears on license)

Drivers License Number

State

Date of Birth

GENERAL UNDERWRITING QUESTIONS

Do employees work in pairs?

Yes
No

Are employees supervised on the job?

Yes
No

Are single‐person jobs limited to experienced staff?

Yes
No

Are periodic unannounced job site management checks performed?

Yes
No

Are written applications completed by all prospective employees?

Yes
No

Are references checked?

Yes
No

Does employment application ask about prior criminal acts?

Yes
No

Are criminal background checks performed on all employees?

Yes
No

Any bid or performance bonding needed?

Yes
No

DESCRIBE BELOW ANY LOSS CONTROL & SAFETY MEASURES IN PLACE TO AVOID EMPLOYEE INJURY, AUTO ACCIDENTS, AND CUSTOMER PROPERTY DAMAGE (driver training, loss prevention meetings, new hire training, etc.)

OTHER COVERAGE TO CONSIDER – Please type any comments or requests below

Do you need coverage for trips or work outside the United States?

Would you like an optional Umbrella Quote?

Would you like an Employee Benefits Quote (health, life, disability, long‐term care)?

Would you like an Employment Practices Liability Quote?

Interested in any other coverage not shown above?

Describe Other Coverage requests here:

PLEASE CONTACT YOUR CURRENT AGENT OR INSURANCE COMPANY FOR A CURRENTLY‐VALUED LISTING OF YOUR CLAIMS HISTORY (“LOSS RUNS”) FOR THE PAST 3 YEARS.

Professional Cleaning Services Program

Professional Cleaning – Commercial

General Information

Policy Limits | PROPERTY

Policy Limits | CRIME

Policy Limits | GENERAL LIABILITY

WORKERS COMPENSATION | OWNERS | List below all owners of the business, whether active or inactive.

WORKERS COMPENSATION | List below payroll for all employees EXCEPT OWNERS

Janitorial Services – Labor

Office – Inside

Sales – Outside

Policy Limits – AUTOMOBILE

Policy Limits – UMBRELLA

PROPERTY – Underwriting Questions

GENERAL LIABILITY – Underwriting Questions

AUTOMOBILE – Underwriting Questions

WORKERS COMPENSATION – Underwriting Questions

UMBRELLA – Underwriting Questions

VEHICLE SCHEDULE – Please complete the below or attach a separate schedule of your own

DRIVER SCHEDULE – Please complete the below or attach a separate schedule of your own

GENERAL UNDERWRITING QUESTIONS

OTHER COVERAGE TO CONSIDER – Please type any comments or requests below