Allied General Agency Company
1100 Locust Street, Dept 2002
Des Moines, IA50391-2002
Ph: 888-364-3434 Fax: 866-433-4331
Email:
Crop Spraying (Ground) Liability Application
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE
Applicant’s NameAgency Name
Mailing AddressAgent
Address
Location
Web site AddressPhone
PROPOSED EFFECTIVE DATE: FromTo12:01 A.M., Standard Time at the address of the Applicant
1. Applicant is: Individual Corporation Partnership Joint Venture Other (Specify):
2. Limits of liability: $100,000/$200,000 $300,000/$600,000 $500,000/$1,000,000 $1,000,000/$2,000,000
3. Years in business:_____ List all states in which applicant performs operations: ______
4. Number of employees: Total: ______Full Time: ______Part Time: ______
Number of certified applicators: ______Are non-certified employees under the “direct supervision” of
certified applicators? Yes No
5. Total annual: Payroll: $ ______Gross Receipts: $ ______
6. Description of operation: ______
7. Does applicant subcontract work out? Yes No If yes, explain: ______
______Annual subcontractor costs: $ ______
Are Certificates of Insurance obtained? Yes No
8. Has applicant or key employees ever been citied by the EPA, OSHA or any state or federal regulatory agency
in the past 5 years? Yes No If yes, explain: ______
9. Does the applicant require Seed Merchants Liability? Yes No
10. Does applicant perform herbicide or pesticide application operations in close proximity where neighboring farms certify that their product is grown organically? Yes No
11. Do you sell, supply or distribute any product under your own label? Yes No If yes, explain: ______
______
12. Applicator Information
Name of applicator(s) as it appears on license / Category / License Number / States Licensed13. Total number of acres sprayed in the past 12 months: ______
Type of Work Performed / Percentage by Receipts / Percentage bySubcontractors / Total Cost of Subcontracted Work
Aerial Spraying (crop dusting)
Anhydrous Ammonia
Application by Mobile Equipment
Application by Hand Held Spraying
Application by tank mounted trucks
Applying Chemicals on owned crops
Applying fertilizers, pesticides or fungicides on non crop exposures (buildings, lawns, golf courses, cemeteries, etc.)
Field Crops
Right of Way
Seed Treatment
Other – Explain
Polyuethane Tanks
Stainless Steel Tanks
14. How chemicals are stored:
Chemical Name / Tank / Other Than Tank / Storage Capacity15. List types of farm machinery or other mobile equipment used in applicant’s operation: ______
______
______
16. What procedures are followed and verified that all tanks have been flushed and cleaned prior to start of each application? ______
______
17. What precautions are taken to make sure the correct field is being sprayed? ______
______
18. Please list top 5 clients:
1.) ______2.) ______
3.) ______4.) ______
5.) ______
19. Does applicant have other business ventures for which coverage is not requested? Yes No If yes, explain: ______
20. Loss Experience for General Liability and Property last 3 years (or # of yrs in business if < 3 yrs) No Losses
YEAR / COMPANY / POLICYNUMBER / PREMIUM / LOSSES
PAID / LOSSES
RESERVED / DESCRIPTION
Prior Carrier: Was prior coverage ever cancelled or non-renewed? Yes No
If yes, please explain:______
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE:Date:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE:Date:
INSPECTION/AUDIT CONTACT NAME & PHONE NUMBER:______IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued. FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Notice To Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. Notice To Maine Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
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