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									                                         STATEWIDE INSURANCE CORP.
                                              P.O. Box 30527, Phoenix, Arizona 85046

                                        Service Contractors Program
                                         Colony Insurance Company
                                    General Liability - Coverages and Rates

Insured:                                                        Policy #:
Effective:                                                      Agency:

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

                                          FINAL COMPUTATIONS

                              General Liability:                      $0
                              Add'l Insureds:                         $0
                              E&O Coverage:                           $0
                                Sub-Total                             $0
                              Policy Fee                              $0
                              Terrorism:         Rejected             $0
                              Taxes / Fees:                          $0.00

                                  Total                        See Note Below

                              Premium Not Offered; Please Select Deductible

/6deed822-be14-44ef-aea3-072395dc51aa.xls                                                                    Revision 10/08

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