Trucker Worker Compensation Checklist

(Serving California since 2004)

P.O. Box 611684, San Jose, CA 95161
Phone & Text 209-645-9620
Sark@Sarkinsurance.com
EFFECTIVE DATE: 04-01-2024 POLICY TYPE: Existing

BUSINESS NAME: Chahal 22 Inc INITIAL FILLING: 2022

EXPERIENCE MODE: BUREAU NO:

LOSS RUN: PRIOR CARRIER INFORMATION:

BUSINESS ADDRESS: 4531 ROMANO DR APT 449

STOCKTON, CA 95207

EMPLOYER IDENTIFICATION (EIN) OR S.S.N.: 881125597

BUSINESS: TRUCKING

BUSINESS PHONE NUMBER: (209) 715-0129

EMAIL: CMANJINDER33@GMAIL.COM

MAIN CONTACT PERSON NAME AND HIS/HER PHONE #: MANJINDER SINGH CHAHAL
( 100% OWNER)
TYPE OF BUSINESS: REFER

CIRCLE ONE - (SAND & GRAVEL / INTERMODAL / DRY / REFER, LOG TRUCK, TAXI OR TOWING)

NAME OF CORPORATION (OWNERS) OR LLC (MEMBER) OR OFFICER:

TOTAL # OF DRIVERS: 1 NO. OF TRUCKS: 1

DRIVER MONTHLY PAYROLL: 60000 CURRENT PAYROLL:

TOTAL # OF CLERICAL STAFF: CLERICAL MONTHLY PAYROLL:

TOTAL # OF SECURITY GUARD: SECURITY GUARD MONTHLY PAYROLL:

IMPORTANT REQUIRED INFORMATION:

1. DOT NUMBER: 3842220 2.MCP (CA NUMBER LOCAL CLIENT): 1397671