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SCIS Fillable Audit Form

* required field
Insured Name:*
Policy #:*
Policy Period From:*
Policy Period To:*
Actual Gross Receipts* 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?  $
Name:*
Title:*
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 omissions 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.
*"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