GL- FOR ELECTRICAL CONTRACTORS SUPPLEMENTAL

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

I HOLD, OR HAVE HELD, THE FOLLOWING LICENSES:

$
$

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:

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

Clear
Signature

Signing Dates

To