KHI Quote Information Worksheet

Producer:

Referred by:

Name:

CA#

MC#

Dba:

Mailing Address:		Zip:
Garaging Address:		Zip

Email:

Phone:

Cell:

Fax:

What exactly do you haul?
(No "General Freight",
be specific)

Drivers:

Any drug or alcohol convictions past 5 years:

Yes

Years in Business:

Radius (specific # in Miles):

Annual Mileage

Limits of Liability $750,000:

$1,000,000:

General Liability Limit:

Cities or States traveled:

Physical Damage? Yes

Deductible:

Amount of Cargo Cov:

Ded:

Refer Brkdn Yes

Has your truck ins. ever been
non-renewed/cancelled?

Yes

If Yes, Why?

Current Company:

Policy#

Exp. Date:

Claims Descriptions:
When & What Happened?
Be specific:

Can you provide loss runs? Yes

Premium needed?

Remarks:

KHI Truck Insruance
23001 La Palma Avenue, Suite 130
Yorba Linda CA 92887
Telephone: 714.692.5411