V.I.P. Program Qualification Form
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Contact Us
Botson Insurance Group
36480 Detroit Road, Avon, OH 44011
440-537-2292
Gbotson@higginbotham.net
botsoninsurancegroup.com
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.
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Business and Personal Information
Business Name
State(s) of Operation
Business Website
Business Address
City
State
Zip Code
Primary Contact's Name
Primary Contact's Phone Number
Primary Contact's Email Address
Policy Information
Are you an OLA member?
Yes
No
Renewal Date for Current Policy (mm/dd/yyyy)
Years in Business
Tax ID Number
Your Company
Breakdown of Type of Work Performed by Company
Residential
Commercial
Industrial
Other
Total (100%)
Percentage of Work
Total Annual Sales ($)
Number of Owners
Number of Employees
Office Payroll ($)
Total Field Payroll ($)
In the below table, please indicate estimated amounts for each operation for the next 12 months. If your company does not perform a service listed in the table, please leave that row
blank
.
% of Operation (%)
Subcontractor Cost ($)
Design Build Work
Lawn Mowing and Maintenance
Snow and Ice Removal
Fertilizing
Tree/Stump Removal
Sprinkler/Irrigation Systems
Pool Installation and Service
Excavation
Other (please describe in third box)
Total % of Operation from Table (Should equal 100%)
Your Company
Breakdown of Type of Work Performed by Company
Residential
Commercial
Industrial
Other
Total (100%)
Percentage of Work
Total Annual Sales ($)
Number of Owners
Number of Employees
Office Payroll ($)
Total Field Payroll ($)
In the below table, please indicate estimated amounts for each operation for the next 12 months. If your company does not perform a service listed in the table, please leave that row
blank
.
% of Operation (%)
Payroll ($)
Subcontractor Cost ($)
Design Build Work
Lawn Mowing and Maintenance
Snow and Ice Removal
Fertilizing
Tree/Stump Removal
Sprinkler/Irrigation Systems
Pool Installation and Service
Excavation
Other (describe in fourth box)
Total % of Operation from Table (Should equal 100%)
Insurance and Program Information
Your Safety and Loss Control Program
Do you have a formal program for the following areas?
Subcontractor Risk Transfer Agreement & Sub-Hiring Program
Yes
No
Equipment Use Training and Field Safety Program
Yes
No
Auto Fleet Safety & Maintenance Program
Yes
No
Equipment Use Training and Field Safety Program
Yes
No
Building Maintenance Program
Yes
No
Your Property Locations
How many locations does your company have?
Please input details on your five largest locations/properties below.
Building 1
Address
Building Limit
Contents Limit
Square Footage
Construction
Please select...
Frame
Metal Non-Combustible
Masonry Non-Combustible
Jointed Masonry
Year Built
Building Use
Please select...
Office
Warehouse
Office Warehouse
Roof Age
Please select...
1-5 years
6-10 years
11-15 years
16-20 years
21-30 years
30+ years
HVAC Age (in years)
Building 2
Address
Building Limit
Contents Limit
Square Footage
Construction
Please select...
Frame
Metal Non-Combustible
Masonry Non-Combustible
Jointed Masonry
Year Built
Building Use
Please select...
Office
Warehouse
Office Warehouse
Roof Age
Please select...
1-5 years
6-10 years
11-15 years
16-20 years
21-30 years
30+ years
HVAC Age (in years)
Building 3
Address
Building Limit
Contents Limit
Square Footage
Construction
Please select...
Frame
Metal Non-Combustible
Masonry Non-Combustible
Jointed Masonry
Year Built
Building Use
Please select...
Office
Warehouse
Office Warehouse
Roof Age
Please select...
1-5 years
6-10 years
11-15 years
16-20 years
21-30 years
30+ years
HVAC Age (in years)
Building 4
Address
Building Limit
Contents Limit
Square Footage
Construction
Please select...
Frame
Metal Non-Combustible
Masonry Non-Combustible
Jointed Masonry
Year Built
Building Use
Please select...
Office
Warehouse
Office Warehouse
Roof Age
Please select...
1-5 years
6-10 years
11-15 years
16-20 years
21-30 years
30+ years
HVAC Age (in years)
Building 5
Address
Building Limit
Contents Limit
Square Footage
Construction
Please select...
Frame
Metal Non-Combustible
Masonry Non-Combustible
Jointed Masonry
Year Built
Building Use
Please select...
Office
Warehouse
Office Warehouse
Roof Age
Please select...
1-5 years
6-10 years
11-15 years
16-20 years
21-30 years
30+ years
HVAC Age (in years)
Your Equipment Floater Limits
Limit
Valuation
Deductible
Misc. Small Tools (under $5,000 per item)
Please select...
Replacement Cost
Actual Cash Value
Please select...
$1,000
$2,500
Scheduled Equipment (over $5,000 per item)
Please select...
Replacement Cost
Actual Cash Value
Please select...
$1,000
$2,500
$5,000
Your General Liability Limits
Liability Limit ($)
Please select...
$300,000
$500,000
$1,000,000
Umbrella Limit ($)
Please select...
$1 million
$2 million
$3 million
$4 million
$5 million
Errors & Omissions Coverage?
Please select...
Yes
No
Unsure
Your Commercial Auto Limits
Liability Limit
Please select...
$300,000
$500,000
$1,000,000
Uninsured Motorist Limit
Please select...
$300,000
$500,000
$1,000,000
Med Pay
Please select...
$1,000
$2,000
$5,000
Comp Deductible
Please select...
$1,000
$2,000
$3,000
Collision Deductible
Please select...
$1,000
$2,000
$3,000
Underwriting
Estimated paid claims in the last three (3) years ($)
Please check ALL (if any) of the following services that your company provides.
Plowing
Tree Removal
Pools
Fertilizing
Plowing
Do you provide services for big box stores?
Yes
No
Do you provide services for streets, roads or highways?
Yes
No
Please list your top four (4) snow clients below.
Client #1
Client #2
Client #3
Client #4
Tree Removals
Maximum Height of Trees (in feet)
Do you work alongside roads or highways?
Yes
No
Do you use cranes?
Yes
No
Pools
Estimated Number of Pools Installed Per Year
Do you use cranes?
Yes
No
Do you install diving boards?
Yes
No
Estimated Number Installed Per Year
Do you install slides?
Yes
No
Estimated Number Installed Per Year
Fertilizing
Are you herbicide/pesticide licensed?
Yes
No
Your Vehicles / Trailers
As a numeral (1, 25, etc.), how many vehicles/trailers does your business use? Include all owned, loaned and leased vehicles/trailers.
Please complete the "Vehicle Information" section for EACH of your vehicles. Click "Add another vehicle" to add information for additional vehicles.
Vehicle Information
Year
Make
Model
VIN
Radius
Please select...
0-50
51-100
101-200
Cost New ($)
GVW
Please select...
0-10,000
10,001-20,000
20,001-45,000
Over 45,000
Ownership
Please select...
Own
Loan
Lease
Your Drivers
As a numeral (1, 25, etc.), how many drivers does your business employ?
Please complete the "Driver Information" section for EACH of your drivers. Click "Add another driver" to add information for additional drivers.
Driver Information
Driver Name
Driver License Number
Your Current Insurance Program and Commitment
Your Current Insurance Program Ranking
For the following items, please indicate your satisfaction level with the services in your current insurance program.
Very Dissatisfied
Dissatisfied
Neutral
Satisfied
Very Satisfied
Agent's knowledge of your industry
Agent's knowledge of your business
Your relationship with your agent
Cost of your insurance program
Handling of claims
Handling of changes to your policy
Safety and loss control resources
Overall value provided
Your Commitment
Your estimated insurance budget to join our program ($)
Your target date to join our program (mm/dd/yyyy)
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