General Liability FOR LANDSCAPING 0042 (INCLUDING TREE TRIMMERS) SUPPLEMENTAL

Please complete the survey to the best of your ability. We aim to cover all aspects comprehensively.

First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

Postal code

Business Name *

Business Phone Number *

Years of Experience *

Years in Business *

Website

Description of day-to-day operations *

I HOLD, OR HAVE HELD, THE FOLLOWING LICENSES:

License#1

License#2

LARGEST JOB IN THE LAST 5 YEARS

BREAKDOWN OF WORK IN %

Any hazardous work subcontracted out? (I.e. mold, asbestos, medical waste, etc.)

If, YES please explain..

Do your subcontractors carry their own GL?

Do you require subcontractors to name you as additional insured?

Does your contract with your subcontractor include a hold harmless agreement in your favor?

Any work for condo or townhouse associations or tract homes?

Gross Receipts *

Owner/Officer Payrolls *

Have you filed any lawsuits against any customer in the last 4 years for non-payment of your services?

Has a lawsuit been filed against your company and liability was assumed?

Do you perform any OCIP/Wrap up work?

List the states you operate in:

Have you ever had prior GL coverage? *

Yes

If Yes, Please request and submit loss run report to Team@litespeedins.com and also please fill out the last 3 years loss details below:

Last 3 Year Loss Summary.. (Please fill the details to the best of your knowledge)

If No, please sign the STATEMENT OF NO LOSS
below:

I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTS OR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDER THE INSURANCE POLICY :

Signature

Signing Dates

From Last 5 Year

Date and Time Signed