Franco Nicolich239-772-4002 Franco.Nicolich@FDean.com Lawn Care Business Insurance Application Full Legal Name of the Proposed Policyholder * Type of Organization * Corporation LLC Individual / Sole Proprietor Partnership / Joint Venture Not-for-Profit Other Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Details Contact Person * First Name Last Name Phone * (###) ### #### Email * Website http:// Insurance Information Coverage Start Date * MM DD YYYY Does your Organization have any specific insurance requirements? Please list any specific requirements you may have. (If none, leave blank) Underwriting Questions Is your business operated out of your home? * It's ok if it is. ;) Yes No How many owners are there in your company? * What is your employee payroll for the next 12 months (include part-time and full-time)? * How many employees are there in your company (include part-time and full-time)? * Does your business provide any of the following operations, goods, or services? * Check all that apply Excavation Property preservation services Tree removal None of the above For the next 12 months, what is your business's expected revenue? * Would you like to include Business Property and Equipment Coverage? * $5,000 $10,000 $15,000 $20,000 $25,000 None Do you require a Waiver of Subrogation? * Yes No Not sure Do you require Primary and Non-Contributory? * Yes No Not sure The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this proposal and declares all statements set for herein are true, complete, and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the submission and the insurer’s receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage. It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not applicable until accepted. * Agree Thank you for submitting your application. We will get back you shortly with your requested quote.
