P.O. Box 80663 • Baton Rouge, La. • 70898-0663
225-927-3283 • 800-893-9887 • 225-927-3295 (Fax)
Email address: Info@LIPCA.com

 

PEST CONTROL OPERATOR GENERAL LIABILITY APPLICATION

INSTRUCTIONS: This entire Application must be completed. Read all questions carefully and provide complete answers. Failure to provide complete information will result in delay in consideration of this Application. This Application is NOT an insurance policy and the COMPANY affording coverage reserves the right to reject any application for any reason. If additional space is needed, attach details to Application on a separate sheet of paper.

If you would prefer to download and print the General Liability Application and mail it in you may do so here.
BROKER / AGENT INFORMATION
Name
Address
City State Zip
Telephone () - Fax () - County/Parish
Producer Name Email Cell () -
CSR Name Email Agency Website
Federal ID or SSN   National Producer Database #
APPLICANT INFORMATION
Applicant Name, if Sole Proprietor
Company Name or DBA
Mailing Address
City State Zip
Telephone () - Fax () - Cell () -
Email     Contact Name
Federal ID or SSN County/Parish Applicant Web Site
Business Type: Corporation  
Partnership  
Sole Proprietorship  
LLC  
Name of Licensed Pest Control Operator/Applicator      License #
Date your current policy expires or when you want the new policy to be effective / /
How many years experience does the licensed operator/applicator have in the pest control industry?
How long have you owned this company?
(If in business less than 3 years, name and location of previous pest control employer
)
Are you a member of any pest control association
Yes  
No  
If yes, whoch one(s)?
Number of Employees: Pest Control Termite Control Non-Contract Inspections Fumigation
Category(ies) Licensed in which to do business: Hold CTRL when clicking to select multiple items
NOTICE: You will not be able to make changes to this document as you move forward. Please check to be sure all your information is correct.
 
 
Revised 02/11