GENERAL INFORMATION
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Entity Name: (legal entity name)
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Office Pride
DBA |
Franchisee#
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Date Needed:
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Mailing Address:
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City:
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State:
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Zip Code:
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Street Address:
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City:
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State:
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Zip Code:
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Contact:
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Title:
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Phone:
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Email:
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Entity Type:
(Corp, LLC, Sole Proprietor)
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FEIN:
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Date Started Business:
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| States in which you operate or intend to operate in the next 12 months:
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| Anticipated Gross Revenue for upcoming 12 months:
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Gross Revenue for past 12 months:
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| Office Payroll:
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Janitorial Payroll:
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Outside Sales Payroll:
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# Employees
FT
PT |
# Employees
FT
PT |
# Employees
FT
PT |
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Owners, Officers, Partners, Members |
| Name:
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Title:
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Annual Salary:
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% Ownership:
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| Name:
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Title:
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Annual Salary:
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% Ownership:
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| Name:
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Title:
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Annual Salary:
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% Ownership:
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| Name:
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Title:
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Annual Salary:
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% Ownership:
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INSURANCE HISTORY FOR THIS ENTITY
Information by Type Coverage |
Property Information
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Insurance Company Name:
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From Date:
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To Date:
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Policy Number:
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| Cancelled or Not Renewed
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# Claims in last 3 years:
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$ Claims last 3 years
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| Gen Liab Information |
Insurance Company Name:
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From Date:
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To Date:
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Policy Number:
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| Cancelled or Not Renewed
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# Claims in last 3 years:
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$ Claims last 3 years
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| Bus Auto Information |
Insurance Company Name:
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From Date:
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To Date:
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Policy Number:
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| Cancelled or Not Renewed
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# Claims in last 3 years:
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$ Claims last 3 years
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| Work Comp Information |
Insurance Company Name:
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From Date:
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To Date:
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Policy Number:
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| Cancelled or Not Renewed
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# Claims in last 3 years:
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$ Claims last 3 years
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| Umb Information |
Insurance Company Name:
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From Date:
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To Date:
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Policy Number:
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| Cancelled or Not Renewed
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# Claims in last 3 years:
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$ Claims last 3 years
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| Janitorial Bond Information |
Insurance Company Name:
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From Date:
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To Date:
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Policy Number:
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| Cancelled or Not Renewed
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# Claims in last 3 years:
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$ Claims last 3 years
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Any other insurance in place other than what is listed above?
If yes, please describe.
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| PROPERTY |
| Age of Building:
Type of Construction:
Square Footage:
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# Stories:
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| Fire/Burglar Alarms: Describe:
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| Subject of Insurance: |
Replacement Value: |
Deductible Desired: |
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| Building: |
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| Business Contents: |
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| If building owner requires to be listed on your policy, please provide information below: |
| Name:
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| Address:
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City:
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State:
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Zip Code:
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Contact Name:
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Email Address:
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Fax Number:
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Phone Number:
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| TOOLS & EQUIPMENT |
| Subject of Insurance: |
Replacement Value: |
Deductible Desired: |
All tools under $2,500 in
individual value |
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Individual Tools & Equipment
with
individual
values over $2,500 |
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Items - Serial# - Actual Cash Value |
| Item #1:
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Serial #1:
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Cash Value #1:
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| Item #2:
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Serial #2:
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Cash Value #2:
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| Item #3:
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Serial #3:
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Cash Value #3:
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| AUTOMOBILE: (VEHICLES MUST BE TITLED IN CORPORATE NAME) |
| Vehicle #1 |
Year:
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Make:
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Model:
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Vin#:
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Comp Ded:
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Coll Ded:
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Loan/lease- Name of Financing:
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| Vehicle #2 |
Year:
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Make:
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Model:
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Vin#:
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Comp Ded:
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Coll Ded:
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Loan/lease- Name of Financing:
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| Vehicle #3 |
Year:
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Make:
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Model:
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Vin#:
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Comp Ded:
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Coll Ded:
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Loan/lease- Name of Financing:
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| Vehicle #4 |
Year:
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Make:
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Model:
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Vin#:
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Comp Ded:
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Coll Ded:
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Loan/lease- Name of Financing:
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| Vehicle #5 |
Year:
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Make:
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Model:
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Vin#:
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Comp Ded:
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Coll Ded:
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Loan/lease- Name of Financing:
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Drivers
(Please provide the name of the drivers as their name appears on license.) |
| Name:
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Date of Birth:
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License#
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State Licensed:
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| Name:
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Date of Birth:
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License#
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State Licensed:
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| Name:
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Date of Birth:
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License#
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State Licensed:
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| Name:
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Date of Birth:
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License#
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State Licensed:
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| Name:
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Date of Birth:
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License#
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State Licensed:
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| INSURANCE REQUIREMENTS ARE: |
Janitorial Bond: $10,000 per employee
General Liability: $1,000,000 per occurrence/$2,000,000 Aggregate
(General and Products/Completed Operations)
Excess Liability: $1,000,000
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Hired/Non-Owned Auto Liability: $1,000,000
Workers Compensation: $1,000,000 |
Additional Insured: Faith Franchising Company Inc and Office Pride Inc,
as well as Area Director
if applicable
PLEASE PROVIDE AREA DIRECTOR NAME:
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GENERAL UNDERWRITING QUESTIONS
Proposals will be provided that either meet or exceed the requirements of the Franchise Contract
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Is a formal safety program in operation?
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Any exposure to flammables, explosives, chemicals?
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Do you install, service, or demonstrate products?
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Do you provide guarantees, warranties, or hold harmless agreements?
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Any exposure to radioactive/nuclear materials?
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Any operations involving storing, treating, discharging, applying, disposing, or
transporting of hazardous material?
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Do you lease employees to or from other employers?
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Have any crimes occurred or been attempted on your premises
within the last three years?
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Do over 50% of employees use their autos in the business?
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Is there a vehicle maintenance program in operation?
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Are any vehicles leased to others?
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Any vehicles customized, altered or have special equipment?
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Do operations involve transporting hazardous materials?
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Any vehicles used by family members? If so, identify below.
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Do you obtain motor vehicle records for new drivers?
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Any drivers with moving traffic violations?
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Do you have an Experience Modification Factor on Work Comp?
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If so what is that factor and when is it effective?
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Any work performed underground or above 15 feet?
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Are you engaged in any other type of business?
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Group transportation provided?
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Any seasonal employees?
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Do employees travel out of state?
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Are physicals required after offers of employments are made?
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Are employee health plans provided?
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Do any employees predominantly work at home?
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Is bridge, dam, or marine work performed?
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Is contract or agreement made with customer? If so, attach copy.
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| Do you own, rent, or otherwise use cranes or scaffolds?
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Do employees work in pairs?
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Employees supervised on the job?
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Are single-person jobs limited to experienced staff?
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Are periodic unannounced job site management checks performed?
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Written applications completed by all prospective employees?
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Are references checked?
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Does employment applications ask about prior criminal acts?
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Are criminal background checks performed on all employees?
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Do You Subcontract any Work to Others?
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Do you perform any bio-hazard cleaning or removal?
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Please provide explanation for any Questions above with a "Yes" answer below:
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Commercial Lines