General Liability FOR tools and equipment

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 Held#1
State Issued#1
Date Issued#1
Expiration Date#1

License#2

License Held#2
State Issued#2
Date Issued#2
Expiration Date#2

LARGEST JOB IN THE LAST 5 YEARS

1:- Company
2:- Description of Duties
3:- Start Date
4:- End Date
5:- Cost/$

BREAKDOWN OF WORK IN %

1:- Residential %
2:- Commercial %
3:- New %
4:- Remodel %
5:- Subcontracted/1099s%
6:- Subcontractor Cost/$

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)

a:- Year
b:- Carrier
c:- Premium
d:- Claims
e:- Incurred
f:- Comments

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 :

Clear

Signature

Signing Dates

From Last 5 Year

Date and Time Signed

Contractor Business Information

Type of Construction Projects.

Yearly Revenue.

Number of Employees

Equipment and Tools Information

Type of Tools and Equipment Used.

Type of Tools and Equipment Used other than above mentioned tools.

Estimated Total Value of Tools and Equipment.

Storage of Tools and Equipment When Not in Use.

Storage of Tools and Equipment When Not in Use other than onsite & offsite.

Frequency of Equipment and Tool Transportation.

Daily

Weekly

Monthly

Rarely

Risk Management and Past Claims

Have you had any equipment or tools lost, damaged, or stolen in the last 5 years?

Yes

If yes, please provide details of any equipment or tools lost, damaged, or stolen in the last 5 years.

Current Measures in Place to Protect Equipment and Tools.

Other than aforementioned Protect Equipment and Tools.

Insurance History and Needs

Current Insurance Policies.

Policy other than above mentioned policies.

Have you previously had inland marine coverage for your tools and equipment?

Yes

If yes, why are you considering a change?

What specific concerns or needs do you have regarding inland marine coverage?

Additional Comments or Questions.