Arborist and Tree Trimming Form

Applicant First Name

Last Name

Email Address

Contact Number

Business Address

City

State

Zip / Postal Code

Years under current management

Website

Number of active owners/officers/partners

In which state(s) do you conduct business?

Please provide the total number of full-time employees (including owners and officers)

Total number of part-time employees

Please check all of the services below that you provide and list the estimated annual amount of payroll for each, excluding the owner's salary. Please check all of the services below that you provide and list the estimated annual amount of payroll for each, excluding the owner's salary. Arborist Tree Trimming Stump Grinding Lawn Care Landscaping Snow Removal Sub-Contractor Costs Others

Arborist Estimated Annual Payroll Amount ($)

Tree trimming Estimated Annual Payroll Amount ($)

Stump grinding Estimated Annual Payroll Amount ($)

Lawn Care Estimated Annual Payroll Amount ($)

Landscaping Estimated Annual Payroll Amount ($)

Snow Removal Estimated Annual Payroll Amount ($)

Sub-contractor Estimated Annual Cost ($)

Other Estimated Annual Payroll Amount and Description

If arborist work is performed, please describe the services provided along with the name and credentials of all arborists.

Do you do any work around power lines for utility companies or governmental entities? Do you do any work around power lines for utility companies or governmental entities? Yes No

Do you do any work for railroad companies? Do you do any work for railroad companies? Yes No

Do you use any pesticides or herbicides? Do you use any pesticides or herbicides? Yes No

If Yes, please describe what type and how often.

Do you use cranes in your operations? Do you use cranes in your operations? Yes No

If Yes, are cranes leased or rented from others? If Yes, are cranes leased or rented from others? Yes No

Leased Rented: Leased Rented: With operator Without operator

Describe operations and frequency of use for leased or rented cranes.

List down all owned cranes . Include -Year , Manufacturer, Max. height , Lifting capacity and Use

Are all crane operators certified? Are all crane operators certified? Yes No

Do you lease or rent your owned cranes to others? Do you lease or rent your owned cranes to others? Yes No

Leased rented: Leased rented: With operator Without operator

Leasing/rental frequency in average days per year

Describe any crane leasing/rental to others for other than arborist-related operations.

Do you obtain Certificates of Insurance verifying general liability coverage limits at least equal to your own and listing you as an additional insured? Do you obtain Certificates of Insurance verifying general liability coverage limits at least equal to your own and listing you as an additional insured? Yes No

Do you assume anyone else's liability in your contracts? Do you assume anyone else's liability in your contracts? Yes No

Do you plow any city streets or highways? Do you plow any city streets or highways? Yes No

If coverage is needed for the plow equipment, please provide year, make, model and value of the plow.

Any person who knowingly conceals or provides materially false, incomplete, or misleading information on an application or concerning a claim to an insurance company for the purpose and intent of defrauding the company, may be guilty of insurance fraud in violation of state law. Penalties may include imprisonment, fines, or denial of insurance benefits. The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact or information. I understand that if the information supplied on this questionnaire changes between the date of the questionnaire and the inception date of the policy period, I will notify Advantage Insurance Solutions of such change. I understand that completion of this questionnaire does not compel the company to provide coverage. Any person who knowingly conceals or provides materially false, incomplete, or misleading information on an application or concerning a claim to an insurance company for the purpose and intent of defrauding the company, may be guilty of insurance fraud in violation of state law. Penalties may include imprisonment, fines, or denial of insurance benefits. The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact or information. I understand that if the information supplied on this questionnaire changes between the date of the questionnaire and the inception date of the policy period, I will notify Advantage Insurance Solutions of such change. I understand that completion of this questionnaire does not compel the company to provide coverage. I understand and agree.