H.L. Staebler Company Limited

The Best Insurance Is An Insurance Broker

Trucking Insurance

Company Information

Company Name:

Address:

City:

Province:

Postal Code:

Contact Person:

Email Address :

Phone Number:

Type of Risk:

Years of Experience:

Present Insurer:

Expiry Date:

	/		/
yyyy		mm		dd

Claims History last 5 years:

Conviction History last 5 years:

Radius of operation:

Province & average
Distance Travelled:

If any U.S. operations,
please advise:

Driver Information

Name:

Age:

Experience:

Vehicle Schedule

Year:

Make:

Model:

Limit Price :

List Price New/Actual Value:

Coverages

Liability Limit:

All Perils Deductible:

Disclaimer:

H.L. Staebler Company Limited is not responsible for instructions not received and acknowledged by a confirmation via e-mail or phone call. By submitting this form, you acknowledge that you are the policyholder and the events described on this form are truthful. Only the person named as the insured in the policy documents can submit a claim report on this policy. All policy terms and conditions apply, subject to policy status at time of submission.