Great Scot! Insurance, Inc.

12155 Metro Parkway, Ste. 28A, Ft. Myers, FL   33912-8302

Phone: (239) 561-3400    (800) 927-0418

Fax: (239) 561-0496

www.gsiinsurance.com

LIABILITY QUOTE INFORMATION

Proposed Effective Date:

Name of Company:

Office Contact:

Mailing Address:

Business Location:

County:

Phone Number:

Fax Number:

E-Mail Address/Web Site:

CORPORATION

r

SOLE PROPRIETOR

r

PARTNERSHIP

r

PCO license number:

FEIN / SSN:

Year business started:

Years in industry:

No. of employees:

Fiscal year ends:

Liability limits desired:

$500,000 per occurrence

r

$1,000,000 per occurrence

r

Anticipated total gross receipts for the next policy period, from all sources:

Pest Control (GHP):

Fumigation:

Termite: Sales (New):

Termite: Renewals:

Termite: Pretreats:

Termite: Baiting Systems:

Brand:

Termite: WDO Inspections:

e.g.: Sentricon

Lawn & Ornamental - Sales:

L & O Payroll:

Landscape Mntc - Sales:

Mntc Payroll:

How many company vehicles do you have?

Transit Pollution required?

r Yes

r No

Which Pest Control Association(s) do you belong to?

r FPMA    r CPCO    r COSWFL    r NPMA    r Other

* In order to apply for rate experience discounts, please list General Liability insurance experience for the past four (4) years.

CURRENT YEAR:

COMPANY:

LOSSES:

1st PRIOR YEAR:

COMPANY:

LOSSES:

2nd PRIOR YEAR:

COMPANY:

LOSSES:

3rd PRIOR YEAR:

COMPANY:

LOSSES: