Supplemental Janitorial Services Application Form

To submit this form, ensure all sections are completed accurately and the form is signed and dated by an owner, officer, or partner. You can submit the completed form via email, fax, or mail to the designated contact information for AmTrust E&S Insurance Services. It's advisable to keep a copy of the submitted form for your records and follow up with the insurance provider if you do not receive a confirmation of receipt. Contact information for submission: Email: submissions@amtrustgroup.com, Fax: (123) 456-7890, Mail: AmTrust E&S Insurance Services, P.O. Box 1234, Anytown, USA.

The form should be submitted as needed throughout the year whenever there is a need to obtain or update insurance coverage for janitorial services operations. No specific dates are mentioned for 2024 and 2025.

The purpose of the Supplemental Janitorial Services Application Form is to provide detailed information required by underwriters to assess the risk and determine the premium for insurance coverage. It captures comprehensive data about the applicant's business operations, including employee data, subcontracted work, payroll, industries serviced, and safety measures in place. Completing this form accurately is crucial for obtaining the necessary coverage from AmTrust E&S Insurance Services. The collected information also helps insurers determine the level of exposure and potential risks associated with providing janitorial services. Accurate and honest completion of each section ensures that the applicant receives appropriate coverage and that the insurance provider can offer a fair premium based on the assessed risks.

• 1. Applicant Information: Includes fields for name, address, telephone, state/area of operation, description of operations, website, years in business, and zip code.
• 2. Exposure Information: Captures employee data, payroll, annual gross receipts, subcontracted work description, and leased or subcontracted staff details.
• 3. Industries Serviced: Requires information about annual sales generated from various industries serviced, including aircraft, apartments, clinics, hotels, industrial plants, and more.
• 4. Operations Performed: Collects data on payroll and sales for operations performed such as carpet cleaning, construction cleanup, janitorial services, landscaping, painting, recycling, and more.
• 5. Liability Controls / Safety: Focuses on supervisory controls, hiring practices, subcontractors, and safety measures implemented by the applicant.
• 6. Claim History: Gathers information about any pre-existing conditions, pending claims, breach of contracts, job replacements, litigation, and lapses in general liability coverage.

Failing to submit this form can result in the applicant being unable to obtain or renew insurance coverage. It is crucial to complete and submit the form accurately to ensure proper risk assessment and coverage.

• Lapse in Coverage: The applicant may experience a lapse in general liability coverage, exposing the business to financial risks.
• Denial of Insurance: Without the required information, insurance providers may deny coverage, leaving the business unprotected.
• Underwriting Issues: Incomplete information can lead to delays or issues in the underwriting process, affecting the timely issuance of insurance policies.

• 1. Applying for Insurance: Use this form to provide detailed information when applying for new insurance coverage.
• 2. Renewing Insurance: Complete this form when renewing existing insurance policies to update underwriting information.
• 3. Updating Exposure Information: Submit this form when there are significant changes in business operations or exposure that need to be documented.
• 4. Compliance with Insurance Requirements: Use this form to meet the documentation requirements set by insurance providers.
• 5. Risk Management: This form helps in identifying and managing potential risks associated with janitorial services operations.