landscaper pgm rou047 201104
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
LANDSCAPERS PROGRAM APPLICATION General Liability APPLICANT INFORMATION Name Address City, State, Zip Telephone
Contractor License Number (if required)
Policy Term: Business Description:
Individual
Partnership
Corporation
Limits Requested: Occurrence
Other
Personal Injury/Advertising
General Aggregate
Medical Payments
Products/Comp Ops Aggregate
Fire Legal
Property Damage Extension (Care, Custody and Control) Estimated annual payroll $
Estimated annual receipts $
Years in business
Average number of employees
Years experience
Percentage use of part-time employees
Percentage use of subcontractors
%
%
(Note: Subcontractors must provide certificates of general liability and workers' compensation insurance)
Describe applicant's operations (all operations must be eligible in order to qualify for this program) Landscaping, Lawn Care
__________% Residential
__________% Commercial
__________% Other
Percentage of tree trimming and nursery work to total revenue Pesticides, herbicides used?
Any fumigating, spraying?
Any landscape architectural work?
Owners & Contractors Protective?
Largest job (sales) $
%
Typical job (sales) $
Describe any use of cranes or heavy equipment Workers' Compensation insurer and policy number
SAVE rou047-201104
Page 1 of 2
Royal Oak Underwriters, Inc.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
THREE YEAR LOSS EXPERIENCE Date
Losses (description and amounts paid and incurred)
____________
__________________________________________________________________________
____________
__________________________________________________________________________
____________
__________________________________________________________________________
____________
__________________________________________________________________________
Comments _________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________ ____________________________________________ ______________________________________ Applicant Signature
____________________________________________ Producer Name & Address
______________________________________ Date
Reset Form rou047-201104
Submit by E-mail Page 2 of 2
Print Form
SAVE
Royal Oak Underwriters, Inc.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
LANDSCAPERS PROGRAM APPLICATION General Liability APPLICANT INFORMATION Name Address City, State, Zip Telephone
Contractor License Number (if required)
Policy Term: Business Description:
Individual
Partnership
Corporation
Limits Requested: Occurrence
Other
Personal Injury/Advertising
General Aggregate
Medical Payments
Products/Comp Ops Aggregate
Fire Legal
Property Damage Extension (Care, Custody and Control) Estimated annual payroll $
Estimated annual receipts $
Years in business
Average number of employees
Years experience
Percentage use of part-time employees
Percentage use of subcontractors
%
%
(Note: Subcontractors must provide certificates of general liability and workers' compensation insurance)
Describe applicant's operations (all operations must be eligible in order to qualify for this program) Landscaping, Lawn Care
__________% Residential
__________% Commercial
__________% Other
Percentage of tree trimming and nursery work to total revenue Pesticides, herbicides used?
Any fumigating, spraying?
Any landscape architectural work?
Owners & Contractors Protective?
Largest job (sales) $
%
Typical job (sales) $
Describe any use of cranes or heavy equipment Workers' Compensation insurer and policy number
SAVE rou047-201104
Page 1 of 2
Royal Oak Underwriters, Inc.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
THREE YEAR LOSS EXPERIENCE Date
Losses (description and amounts paid and incurred)
____________
__________________________________________________________________________
____________
__________________________________________________________________________
____________
__________________________________________________________________________
____________
__________________________________________________________________________
Comments _________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________ ____________________________________________ ______________________________________ Applicant Signature
____________________________________________ Producer Name & Address
______________________________________ Date
Reset Form rou047-201104
Submit by E-mail Page 2 of 2
Print Form
SAVE
Royal Oak Underwriters, Inc.
