Public Livery Quote

Public Livery Application

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GENERAL INFORMATION

* Indicates required field

Proposed Effective Date: *

A. Applicant’s Name: *

B. Applicant’s Mailing Address: *

City: *

State: *

Zip: *

Email *

County: *

Business Telephone Number *

Fax *

C. Physical Location of Business

City: *

State: *

Zip: *

Please list any other names the business is or has been known by: *

Contact Person: *

Detailed description of business activities (specifically, and by location): *

What year was the business established? *

Annual Payroll: $ *

Total Number of Employees: *

Full-Time: *

Part-Time: *

Has the Applicant or any predecessor ever had a claim? *

Choose Any *

Individual Corporation Partnership Joint Venture

Physical Damage Deductible: *

Others: $ *

BUSINESS OPERATIONS

What is the maximum radius of your operation? *

OPERATOR SCHEDULE

Driver # *

Driver Name: *

SEX (M/F) *

DATE OF BIRTH *

DRIVER’S LICENSE NUMBER *

STATE LIC *

Driver # (D2) *

Driver Name: (D2) *

SEX (M/F) (D2) *

DATE OF BIRTH (D2) *

DRIVER’S LICENSE NUMBER (D2) *

STATE LIC (D2) *

Driver # (D3) *

Driver Name: (D3) *

SEX (M/F) (D3) *

DATE OF BIRTH (D3) *

DRIVER’S LICENSE NUMBER (D3) *

STATE LIC (D3) *

Driver # (D4) *

Driver Name: (D4) *

SEX (M/F) (D4) *

DATE OF BIRTH (D4) *

DRIVER’S LICENSE NUMBER (D4) *

STATE LIC (D4) *

VEHICLE SCHEDULE

Vehicle #: *

Year *

Model *

V.I.N. *

Territory *

Type *

License State *

Radius *

Vehicle #: (V2) *

Year (V2) *

Model (V2) *

V.I.N. (V2) *

Territory (V2) *

Type (V2) *

License State (V2) *

Radius (V2) *

Vehicle #: (V3) *

Year (V3) *

Model (V3) *

V.I.N. (V3) *

Territory (V3) *

Type (V3) *

License State (V3) *

Radius (V3) *

Vehicle #: (V4) *

Year (V4) *

Model (V4) *

V.I.N. (V4) *

Territory (V4) *

Type (V4) *

License State (V4) *

Radius (V4) *

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Califonia Lic # 0801925 | NPN # 2543434

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Champ Insurance Services
California license # 0801925
National Producer # 2543434
92 Corporate Park C 777
Irvine CA, 92606
949-535-1099
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