STATEWIDE INSURANCE CORP.
P.O. Box 30527, Phoenix, Arizona 85046
Service Contractors Program
Colony Insurance Company
General Liability - Coverages and Rates
Insured: Policy #:
Has this insured had prior insurance coverage?
Is this business a New Venture?
Has this insured been claim free with Statewide for more than one year?
PREMIUM MODIFIER = 1.00
GENERAL LIABILITY CALCULATIONS
Please Select Class Description Below
Class Description and Code #:
Occurrence Limit: Please Select Desired Occurrence Limit 0
Do you want Double Aggregate Limits?
General Aggregate Limit:
Deductible ($500/$1,000) Please Select Deductible
Does the Applicant want E&O Coverage?
Additional Insured's Requested ($100 each):
Deductible Double Final Modified Final
Class Code Base Rate Modifier Payroll
Factor Aggregate Rate Premium
0 TOTAL GL PREMIUM $0
TERRORISM PREMIUM $0 Rejected
Accept Terrorism Coverage? Submit Signed Terrorism Form
General Liability: $0
Add'l Insureds: $0
E&O Coverage: $0
Policy Fee $0
Terrorism: Rejected $0
Taxes / Fees: $0.00
Filing Fee: $0.00
Total See Note Below
Premium Not Offered; Please Select Deductible
/7818bd58-1c84-491d-b2df-c4729e29cc0b.xls Revision 10/08