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* required field
Name Of Insured:*
Insured Company Name:*
Insured Current Address:*
Insured Current City:*
Insured Current State:*
Insured Current Zip:*
Policy #:*
Policy Period From:*
Policy Period To:*
Company Type:*
Do you operate your business under more than one name?*
 Yes    No
Please provide the other business names you use: 
Do you own or operate any other separate businesses?*
 Yes    No
What are the names of the other businesses? 
Dates Started: 
Are they insured? 
 Yes    No
What insurance carrier provides the policy? 
Do you have more than one location for your business?*
 Yes    No
What are the other addresses you operate from? 
Are you or your business currently licensed?*
 Yes    No
Has your license ever been suspended or revoked? 
 Yes    No
Do you subcontract out any work to subcontractors?*
 Yes    No
a) Which trades do you subcontract out? 
b) What percentage of your gross receipts are subcontractor costs?  %
c) Do you require that you or your business be added as an Additional Insured to the subcontractors' policy? 
 Yes    No
d) Do you collect the Certificates of Insurance that name you as an Additional Insured to the subcontractors' policy? 
 Yes    No
e) Prior to the subcontractor commencing work, do you execute a written agreement that contains a hold harmless clause in your favor? 
 Yes    No
Do you do perform any work on condominiums or townhomes?*
 Yes    No
Is this work done for the association or for an individual unit owner? 
Are you performing work on any new tract home construction projects?*
 Yes    No
How many homes are you working on? 
How many homes in the tract development? 
Do you have any claims or lawsuits pending against you now?*
 Yes    No
Provide details and dates: 
Have you ever had any claims in the past?*
 Yes    No
Provide details and dates: 
Do you work as a construction manager for any individuals or other entities?*
 Yes    No
Provide details and dates: 
Do you perform any new construction?*
 Yes    No
Please describe your responsibilities on the projects: 
If the insured performs more than one activity on the new constructions projects, provide the percentage of each activity: 
Describe the operations on a typical job:*
Describe the current job in progress:*
What are the estimated annual gross receipts¹ for this current policy period?* $
What were the annual gross receipts¹ for the last policy period?* $
What is the estimated annual payroll, including owner's salary?* $
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" comprise 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