General Liability

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:

Do You Hold Any License ? *

Yes

Do you work under any sub-contractor license ? *

Yes

Please provide as much accurate information as possible.

BREAKDOWN OF WORK IN %

Do your subcontractors carry their own GL? *

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) *

1. Year
2. Carrier

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