Window Cleaning Liability Questionnaire

by Buiten & Associates, LLC

  1. Complete the following Window Cleaning Liability Questionnaire. To fill out on your computer,

simply click the “Yes” or “No” checkboxes with your mouse. To type requested information, click

once on the gray “form field” bar and begin typing.

  1. Completed forms may be e-mailed, faxed or mailed to Buiten & Associates. If you need

assistance with your questionnaire,please contact Brian Mattila at

or Sue Baxter at , fax to (616) 949-0433or call Brian at

(616) 956-0040 or 1-800-530-9221.

  1. Please provide the following information with your completed form: Claims/loss runs on your business

for the past three years. You can get these from your current insurance agent. If you are new in

business or have not had insurance in the past, then we will need a statement on your letterhead whether or not you have had any claims in the past three years.

Please include this information with the completed applicationsend

by e-mail:

by fax: (616) 949-0433

or by mail: 5738 Foremost Dr. SE, Grand Rapids, MI, 49546

Getting Started

Please provide the following information:

Business Name / Contact Name
Address / Phone Number
E-mail address / Date
Names of Owners/Officers / Date Your Business Started
Federal ID Number / Social Security # of Owner(s)

General Information

Choose One: Sole ProprietorPartnershipCorporationLimited Liability Corporation

  1. Please select the type of window cleaning you perform and show percentages for each category. Must add up to 100%.

Residential %

Commercial, <3 stories %

Commercial, >3 stories %

High-rise, >10 stories %

  1. Please indicate your work percentages in total for window cleaning and any other potential type works you may do.

Must add up to 100%.

Window Cleaning %Janitorial Services % Snowplowing %

Duct Cleaning %Pest Control Application % Chandelier Cleaning %

Power washing %Awning Cleaning/Repair %

Carpet/Furniture Cleaning %Glass Restoration/Replacement %

  1. Number of Full Time employees:

Number of Part Time employees:

Number of Owners (include spouses who work for the business):

Are you a Seasonal Business? YesNo

  1. Are warning signs or barricades placed around the worksites?YesNo

Is Pedestrian Traffic restricted through work zones?YesNo

Are precautions taken to prevent injuries to the public?YesNo

Please describe:

  1. Is there formal training involved for new personnel and ongoing training for more seasoned workers? Yes No

Are employees required to wear safety harnesses and lifelines when working above ground level? Yes No

Is the work of all employees adequately supervised?Yes No

Are all ladders, hoists, & scaffolding inspected regularly and maintained in safe operating condition? Yes No

Have you or your business ever been cited or fined by OSHA for any safety violations? Yes No

What chemicals are used in your business?

Are manufacturers’ recommendations closely followed regarding storage, mixing, and usage? Yes No

Please provide any additional comments or information regarding the questions in #5:

  1. Please list your total receipts for the company:

Below, please provide a breakdown of Payroll by work performed on an annual basis.

This is Employee Payroll only, not including owners.

Residential Window Cleaning <3 Stories$

Commercial Window Cleaning <3 Stories $

Commercial Window Cleaning >3 Stories$

Commercial High-rise >3 Stories $

Janitorial Services $

Pest Control $

Duct Cleaning$

Awning Cleaning/Repair$

Glass Restoration/Replacement$

Power Washing$

Snowplowing$

Chandelier Cleaning$

Carpet/Furniture Cleaning$

Any Other Business Activities (describe below)$

Please provide any additional comments or information regarding the questions in #6:

  1. Do you use water-fed poles in your company?YesNo

Up to what maximum height?

  1. If the company has been in business for less than 1 (one) year, please include the owner’s resume with previous work experience. (Attach as separate document.)
  1. Would you like to include an optional quote for a Janitorial Service bond?YesNo

If yes, please indicate desired limit:$5,000$10,000

  1. Has a bond claim ever been made against your company? YesNo

If yes, please explain:

  1. Are you interested in an optional quote on your equipment?YesNo

If yes, please include a schedule of your equipment with descriptions and values for each item. (Please attach.)

  1. Where is your equipment stored when not in use?

If stored in a vehicle, is the vehicle always locked?YesNo

  1. Are you interested in a quote on commercial vehicle insurance?YesNo

If yes, please include the following information:

List all vehicles:

YEAR / MAKE / MODEL / VEHICLE ID NUMBER

List all drivers:

NAME / BIRTHDATE / LICENSE NUMBER / STATE

Have you had any claims made on your vehicle insurance in the past 3 (three) years? Yes No

If yes, please attach information. This information can be obtained by contacting your current agent.

SIGNATURE

The Undersigned warrants that to the best of his/her knowledge and belief the statements set forth herein are true. The Undersigned further declares that any occurrence or event that takes place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Underwriter. The Underwriter is hereby authorized to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The signing of this Application does not bind the Undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is agreed that this Application shall be the basis of the contract should a policy be issued. This Application will be attached and become a part of the policy.

Name: Title:

Date: Signature:

(If filling out electronically, simply type full name as signature.)

The above signed warrants that he/she is authorized and has the power to complete and execute this Application

including the warranty statement on behalf of the Applicant and their respective Directors, Officers, or other insured persons.