GL- FOR ELECTRICAL CONTRACTORS 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 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

Any high voltage work? *

Yes

If yes, for high voltage work please provide details.

Any work on emergency lighting or traffic signals? *

Yes

If yes, for emergency lighting or traffic signals please provide details.