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Today's Date *

Time *

Coverage Date *

Contact Name *

First

Last

Agency *

CAB *

Phone Number *

Fax *

Email *

Insured *

DBA *

Garaging City *

Street *

Zip *

Nature of Business *

Commodities Hauled *

Years in Business *

Losses in 3 Years

LIA $ *

PD $ *

CG $ *

Attach Loss Report(s) for all Accident(s) *

Max file size: 20MB

Radius of Operation

Trailers *

Vehicles

(1) Vehicle Year *

(1) Make Model *

(1) GVW *

(1) Value *

(1) DED *

(2) Vehicle Year *

(2) Make Model *

(2) GVW *

(2) Value *

(2) DED *

(3) Vehicle Year *

(3) Make Model *

(3) GVW *

(3) Value *

(3) DED *

(4) Vehicle Year *

(4) Make Model *

(4) GVW *

(4) Value *

(4) DED *

Trailers

(1) Trailer Year *

(1) Make Model *

(1) GVW *

(1) Value *

(1) DED *

(2) Trailer Year *

(2) Make Model *

(2) GVW *

(2) Value *

(2) DED *

(3) Trailer Year *

(3) Make Model *

(3) GVW *

(3) Value *

(3) DED *

(4) Trailer Year *

(4) Make Model *

(4) GVW *

(4) Value *

(4) DED *

Owner Driven *

Max file size: 20MB

Name of Drivers

(1) Name of Driver *

(3) Name of Driver *

(2) Name of Driver *

(4) Name of Driver *

Filing

Filing Type *

Filing Numbers *

Liability

Liability ($) *

UM *

PIP *

Cargo

Cargo ($) *

DED ($) *

Reefer Breakdown

Reefer Breakdown *

DED ($) *

MVR *

CAB *

Losses *

Comment *

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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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So Cal Coastline photo by Don Ramey Logan | CC BY 4.0
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