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* required field
Name of Insured:*
Policy #:*
Policy Period From:*
Policy Period To:*
Actual Gross Receipts¹ for the policy period:* $
Actual Subcontractor Costs for the policy period:* $
Have you completed any work under a wrap policy?   Yes    No
What are the gross receipts under the wrap policy?  $
Email Address:*
Daytime Phone #:*
 By checking this box, I certify the information I provided in connection with this policy is true, accurate and correct. I understand that any false statements or deliberate omission of information will result in the termination of any policy of insurance that is a renewal of this policy. I also understand that I may be required to provide formal accounting records later as supporting documentation if needed for verification.
¹"Gross Receipts" comprises the total receipts of your business. No deductions for inter-company sales, cost of goods sold, property sold, labor costs, interest expense, discounts paid, delivery costs, state or federal taxes or any other expenses are allowed.   


Shield Commercial Insurance Services, Inc.
43-725 Monterey Ave, Ste A. Palm Desert, CA 92260
Tel: 760-345-9029 Fax: 800-345-4851
CA License Number: 0E67754