McNabb Insurance Services

MCNABB INSURANCE SERVICES

Quick quote for premium indication only. For binding procedures please refer to our web-site. Coverage cannot be bound via the internet.

COMMERCIAL AUTO/TRUCK PROGRAM
Quick Quote Form

* Indicates Required Fields

Producer* :

Producer Contact Name* :

Phone #* :

Fax #* :

Insured Name/DBA* :

Mailing Address* :

City and Mailing Zip Code* :

City and Garaging Zip Code* :

Years Prior Ins*. :

Prior Carrier* :

Maximum Radius (road miles)* :

Filing* :

ICC

DMV

PUC

Subhaul exposure* :

VEHICLE LIST:

Vehicles* :

DRIVER LIST:

Driver #1	Driver #2	Driver #3
Name* :	Name :	Name :
DOB* :	DOB :	DOB :
Yrs Comm'l Lic Exp & Class*:	Yrs Comm'l Lic Exp & Class:	Yrs Comm'l Lic Exp & Class:
Accidents: list of dates	Accidents: list of dates	Accidents: list of dates
Violation codes and conv. dates:	Violation codes and conv. dates:	Violation codes and conv. dates:

Describe type of business*:

Describe and show percent of
All Types of Cargo Hauled:

Claims Reported - Last 3 Years

Total #of Claims:

Claims and Dates:

COVERAGE REQUESTED :

Liability Limit* $:

Bodily Injury Deductible $:

Property Damage Deductibles $:

UM/UMBI Limit $:

UMPD Limit $3500 :

Medical Limit $:

Physical Damage Coverage Deductible $:
applicable to all vehicles for which a stated value is indicated

On-Hook Limit $:

On-Hook Deductible $500 or $1000:

FOR A TRUCKER GENERAL LIABILITY QUOTE PLEASE CONTACT
LOUISE TEBELEKIAN AT (818) 567-0736 EXTENSION 325