license new insurance

THIS SECTION IS FOR PARTIES WHO ARE "LICENSED
TRANSPORTATION BUSINESS OPERATORS" SEEKING TO.......

CHANGE

INSURANCE AGENT

OPERATOR (LICENSE HOLDER) INFORMATION:

P/S COMPLETE FORM BELOW PS/The information you provide below is needed to complete your TCP Application.

COMPANY NAME:
	(The "Legal Name" of your business)
FICTITIOUS NAME:	dba
	(this is a non-legal name used to sell your services)
CalPUC/PSG #:	(TCP or PSC or MTR)
CA NUMBER:
	CA# is the Carrier Profile/File-# assigned to your company by the California CHP). All vehicles designed to carry more than 10 passengers including the driver require CHP Inspection @ a fee $15 per vehicle. CHP Inspection fees are payable to the PUC which coordinates the inspection.
DRIVER LICENSE:	(owner-operator's driver license)
BUSINESS CONTACT:	(Must be an officer)
TITLE:	(must be Owner, President, CEO)
E-MAIL ADDRESS:

PHYSICAL LOCATION OF BUSINESS (WHERE RECORDS ARE KEPT)
BUSINESS ADDRESS:
SUITE/UNIT #:
CITY:		COUNTY:
STATE:		ZIP CODE:
BUSINESS PHONE:	Area-code: Phone #:

TERMINAL ADDRESS IS WHERE YOU KEEP THE VEHICLE LOCATION:
TERMINAL ADDRESS:
CITY:		COUNTY:
STATE:		ZIP CODE:
TERMINAL PHONE:	Area-code: Phone #:

COMMERCIAL INSURANCE AGENT INFORMATION:

Ref: PUC General Order 115-F....
COMMERCIAL INSURANCE LIMITS REQUIRED
SEATING CAPACITY	REQUIRED COVERAGE
7 or Less Passengers	$750,000
8 to 14 Passengers	$1,500,000
15 or more Passengers	$5,000,000
Have your Agent file Certificate of Insurance # "PL914"

You must have an Insurance Agent/Broker at the time of the Application. We may find you an Insurance Agent, if you have not already found one.

CONTACT:

TITLE:

Company Name:

STE#:

Address:

CITY:

STATE:

ZIP CODE:

TELEPHONE:

FAX:

E-mail:

OUR FEES AND CHARGES: Please Pay...
ITEM	DESCRIPTION	FEES
	Our consulting fees for changing commercial insurance agent/broker. (Pay to .......)	$ 50

We are unable to accept payment by credit/debit cards at the present.
PLEASE, CALL US TO PAY BY CHECK AT: 323-378-6494....

MISCELLANEOUS INFORMATION:
(Use box below for any more information to add)