Cooper, Simms, Nelson, & Mosley World Wide Web Site Online Insurance Application
     IMPORTANT NOTICE: Please note that no coverage can be bound using e-Mail, the Internet, or by leaving a voice mail message. All requests must b conducted through our agency with signed applications. 

Toll Free: 1.877.644.2766                                                                                                     Providing Insurance Since 1934

 

 
JANITORIAL
(Commercial/Residential)
Insurance Quote		   We would like to provide you with a free, no-obligation Janitorial insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
 

 

General Information
Name of Business:
Contact Name:
Address:
City:   State:   Zip:
Business Phone:   Fax:
Best Time To Call:   AM   PM
Contact Email Address:
Applicant is: Individual   Corporation   Partnership   Joint Venture
Other:


Limits of Liability
Limits of Liability Requested
General Aggregate $ Each Occurrence $
Products & Completed
Operations Aggregate		 $ Fire Damage (any one fire) $
Personal & Advertising Injury $ Deductible   $


A. How long has applicant been in business?  
Total number of employees:  

 

B. Does applicant have Workers' Compensation coverage in force?   Yes No

 

C. Does applicant lease employees?   Yes No

 

D. Describe operations of applicant:                                                                                                        
 
Office Buildings %   Apartment Buildings %
Industrial Buildings % Hotels %
Shopping mall/center % Theatres/movie houses %
Supermarkets/dept. stores % Hospitals %
Retail stores % Sports complex %
Terminals % Convention halls %
       Airport
       Railroad
       Bus
       Shipyard		   Private residences %
Window cleaning    Max. # of stories    Scaffolds/rigging    Rented   Owned

        Contract with:    

 

E. Annual PAYROLL information:                                                                                                        
 
Janitorial $   Owner $
Window Cleaning $ Employees $
Carpet Cleaning $
Floor Waxing $
Pool Service $
Other $

 

F. Annual SALES information:                                                                                                        
 
Janitorial $   Owner $
Window Cleaning $ Employees $
Carpet Cleaning $
Floor Waxing $
Pool Service $
Other $

 

G. Does risk store L.P.G., flammable liquids, ammunition or explosives on the premises?   Yes No
If so, type and quantity stored:

 

H. Does risk lend, lease, or rent any equipment to others?   Yes No
If so, state the type of equipment involved and the gross receipts derived therefrom:

 

I. Does applicant subcontract work?   Yes No
If so, state type:

Are certificates of insurance required from all subcontractors?   Yes No

 

J. During the past three years has any company ever cancelled, declined or refused to renew similar insurance for the applicant? Yes No
If yes, explain:

Previous Insurer: Indicate premium and losses for the past three years. Describe all losses.

Year Company Policy # Premium Losses
Paid		 Losses
Reserved		 Description


Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

 

   

 

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