Sierra Oak Insurance Services Inc.

Janitorial Liability Form

Contact Name:
Contact Email:
Contact Phone:
Contact Fax:
Applicant Name:
How long have you been in business?
Mix of business:		% Commercial % Industrial % Residential
Employee Data:		Owners number: annual payroll: Employees (full time) number: annual payroll: Employees (part time) number: annual payroll: Leased Employees number: annual payroll: Independent Contractors number: annual payroll:
Annual Sales:
		Type of operations performed (list all):
Do you use wax on floors:		Yes No
Window Cleaning:		Max number of stories: Scaffolding/rigging, if any: Rented Owned
		Please provide a brief description of any hazardous waste handled, storage of combustible material, and recyclables handled:
Are your employees bonded?		Yes No If yes, effective date of coverage: