"Truckers Occupational Accident Application Form - High Point Underwriters"

ADVERTISEMENT
High Point Underwriters - Truckers Occupational Accident Application
ACCOUNT INFORMATION
Legal Name: __________________________________________
[ ] Individual [ ] Corporation [ ] LLC [ ] Partnership [ ] Other
Physical Address: ________________________________________
City:__________________________ State: ______ Zip:______
Contact Person: _________________________________________
Telephone:____________________ FAX: _____________
Email Address: __________________________________________
Motor Carrier’s EIN#: ________________________
#Years in Business:_______
BUSINESS INFORMATION:
SAFER: Motor Carrier ID#:______________________
Motor Carrier’s DOT #: ______________________
Type of Carrier: [ ] Common [ ] Contract [ ] Private [ ] Other: ___________LTL % _____ Truckload % _____
Operations:
1.
Method of Driver Compensation: [ ] Mileage [ ] Revenue [ ] Hourly [ ] Trip [ ] Other (details) _____________________________
2.
Backhaul policy is under the control of ACCOUNT [ ] or at the discretion of the DRIVER [ ] - Check one
3.
Do You haul: Hazardous Waste Material Explosives Flammables Refuse Radioactive Cargo - Check any that apply
4.
Does Account allow passengers: YES [ ] NO [ ] (If YES, give details) _____________________________________________
5.
List Account Terminal Locations:______________________________________________________
6.
Do You lease out drivers to other Motor Carriers? _____ Yes _____ No
7.
Do You allow Passengers? ______ Yes ______ No
8.
Are all Contract Drivers required to execute an Independent Contractor Agreement with the Motor Carrier? _____ Yes _____ No
Round Trip Radius: more than 500 miles _____%
499 to 200 miles _____%
199 to 50 miles _____% less than 50 miles ______%
Type of Equipment: VAN ________% REFRIGERATED _______% FLATBED _______% TANKER _______% DUMP ________%
DOUBLE TRAILERS ____% OVERSIZE/OVERWEIGHT _______% OTHER ___% Details ___________________________
Cargo Hauled: List all commodities hauled by percent of total for the year:
_________________________ _____% ____________________ ____%
_________________________ _____% ____________________ ____%
DRIVER INFORMATION & COMMODITIES HAULED
Total # Drivers:
___________________
# Drivers by Type: Owner Operators:____________ Paid by ____1099 _____ W-2
Contract Drivers: ____________ (Drivers for an Owner Operator) Paid by: ____ 1099 _____ W-2
Company Drivers ____________ (Drives for MC in the Motor Carrier's Equipment) Paid by 1099 only
Team Drivers:__________
Employee Drivers: _________ Paid by W-2 Only
Other Types:
Are Casual Laborers or Helpers used? _____ Yes _____ No. If yes, provide details using Casual Laborer Supplemental Application
General Driver Information: Are Drivers required to report daily: _____YES _____ NO]
Driver’s average length of haul: __________ miles
Driver’s average duration of haul: _____________ days
Driver Load/Unload % _________
What is minimum age: ________ years.
What is maximum age: __________ years
Minimum CDL driving experience _________
Trucking Occupational Accident Application 01/01/16
Page 1 of 3
High Point Underwriters - Truckers Occupational Accident Application
ACCOUNT INFORMATION
Legal Name: __________________________________________
[ ] Individual [ ] Corporation [ ] LLC [ ] Partnership [ ] Other
Physical Address: ________________________________________
City:__________________________ State: ______ Zip:______
Contact Person: _________________________________________
Telephone:____________________ FAX: _____________
Email Address: __________________________________________
Motor Carrier’s EIN#: ________________________
#Years in Business:_______
BUSINESS INFORMATION:
SAFER: Motor Carrier ID#:______________________
Motor Carrier’s DOT #: ______________________
Type of Carrier: [ ] Common [ ] Contract [ ] Private [ ] Other: ___________LTL % _____ Truckload % _____
Operations:
1.
Method of Driver Compensation: [ ] Mileage [ ] Revenue [ ] Hourly [ ] Trip [ ] Other (details) _____________________________
2.
Backhaul policy is under the control of ACCOUNT [ ] or at the discretion of the DRIVER [ ] - Check one
3.
Do You haul: Hazardous Waste Material Explosives Flammables Refuse Radioactive Cargo - Check any that apply
4.
Does Account allow passengers: YES [ ] NO [ ] (If YES, give details) _____________________________________________
5.
List Account Terminal Locations:______________________________________________________
6.
Do You lease out drivers to other Motor Carriers? _____ Yes _____ No
7.
Do You allow Passengers? ______ Yes ______ No
8.
Are all Contract Drivers required to execute an Independent Contractor Agreement with the Motor Carrier? _____ Yes _____ No
Round Trip Radius: more than 500 miles _____%
499 to 200 miles _____%
199 to 50 miles _____% less than 50 miles ______%
Type of Equipment: VAN ________% REFRIGERATED _______% FLATBED _______% TANKER _______% DUMP ________%
DOUBLE TRAILERS ____% OVERSIZE/OVERWEIGHT _______% OTHER ___% Details ___________________________
Cargo Hauled: List all commodities hauled by percent of total for the year:
_________________________ _____% ____________________ ____%
_________________________ _____% ____________________ ____%
DRIVER INFORMATION & COMMODITIES HAULED
Total # Drivers:
___________________
# Drivers by Type: Owner Operators:____________ Paid by ____1099 _____ W-2
Contract Drivers: ____________ (Drivers for an Owner Operator) Paid by: ____ 1099 _____ W-2
Company Drivers ____________ (Drives for MC in the Motor Carrier's Equipment) Paid by 1099 only
Team Drivers:__________
Employee Drivers: _________ Paid by W-2 Only
Other Types:
Are Casual Laborers or Helpers used? _____ Yes _____ No. If yes, provide details using Casual Laborer Supplemental Application
General Driver Information: Are Drivers required to report daily: _____YES _____ NO]
Driver’s average length of haul: __________ miles
Driver’s average duration of haul: _____________ days
Driver Load/Unload % _________
What is minimum age: ________ years.
What is maximum age: __________ years
Minimum CDL driving experience _________
Trucking Occupational Accident Application 01/01/16
Page 1 of 3
Driver Locations By Home State: Give total number of Owner/Operators, Contract Drivers, Team Drivers to be insured by state of residence:
Alabama _________
Idaho _______
Michigan _________
New York ___________
Tennessee ____________
Arizona _________
Illinois ______
Minnesota ________
North Carolina _______
Texas ________________
Arkansas _________
Indiana _____
Mississippi ________
North Dakota ________
Utah _________________
California _________
Iowa _______
Missouri __________
Ohio ___________
Vermont ______________
Colorado ________
Kansas _____
Montana __________
Oklahoma _________
Virginia _______________
Connecticut ______
Kentucky ______
Nebraska __________
Oregon ____________
Washington ____________
Delaware ________
Louisiana ______
Nevada ___________
Pennsylvania _______
West Virginia ___________
Dist of Col _______
Maine _________
New Hampshire _______
Rhode Island ________
Wisconsin _____________
Florida _________
Maryland _______
New Jersey __________
South Carolina ______
Wyoming ______________
Georgia ________
Massachusetts ______
New Mexico __________
South Dakota _______
TOTAL_________________
SAFETY INFORMATION
Does the Account have a specified individual who’s full-time duty is that of a Safety Director? YES [ ] NO [ ] (name:___________________________)
Does the Account have a current written safety/loss control program: YES [ ] NO [ ] - If Yes, please provide the following information:
Who Developed the program? Name: __________________________________________________________________________________
Years of Experience: _______ When was the program initiated: __________________ When was it last updated: _____________________
Does the safety/loss program address the following items:
Inspections of operations, conditions and vehicles to identify hazards?
YES [ ]
NO [ ]
Frequency of Training of owner operators in safe work practices?
YES [ ]
NO [ ]
Specific owner operator rules?
YES [ ] NO [ ]
How often are safety meetings conducted: ______________________ Are Owner/Operators required to attend YES [ ] NO [ ]
How often are Owner/Operator’s MVRs reviewed?: ________________
Maximum number of accidents permitted: _______
Maximum number of violations permitted: _______
What MVR violation would cause Owner/Operator’s Lease Agreement to be “inactive” __________________________________________________
PRIOR INSURANCE PROGRAM AND LOSS INFORMATION
1.
Do you have a current Occupational Accident Program for your Independent Contractors? _______ Yes _______ No
2.
Who is the current carrier?: ______________ What is the Anniversary Date?: ____________ Is the Program mandatory? ____ Yes ____ No
3.
Have you ever had an Occupational Disease, Cumulative Trauma or Contingent Liability type claim? ______ Yes ______ No
4.
Please provide 5 years of currently valued loss information.
Please provide the total annual 1099 settlements and driver counts for the last 5 years:
POLICY TERM
TOTAL PAID AMOUNT OF 1099 SETTLEMENTS
# OF 1099 FORMS ISSUED
CURRENT TERM
FIRST PERIOD
SECOND PERIOD
THIRD PERIOD
FOURTH PERIOD
Has an Independent Contractor filed a Workers' Compensation or Contingent Liability Claim in the last 3 Years? _____YES _____ NO
If Yes, please provide information on those claims.
Has any prior Workers’ Compensation, Occupational Accident, Contingent Liability, or similar coverage been cancelled or non-renewed in the last 3
Years? _____ Yes ____ No. If Yes, please provide information on that program.
Trucking Occupational Accident Application 01/01/16
Page 2 of 3
ADDITIONAL REQUIRED INFORMATION:
1.
Copy of the Lease Agreement & Lease Purchase Agreement (if applicable)
2.
Initial Driver Census - include: Name, DOB, and State of Residence
AGENT IDENTIFICATION AND SIGNATURE
Agency Name:___________________________________________________
City:_____________________________ State:________ Zip:_____________
Agency Contact Person:____________________ E-mail: _________________
Requested Effective Date: __________________________________________
Date Quote Needed: ______________________________________________
Signature of Applicant/Account:______________________________________
Date:____________________________________
Signature of Producer:_____________________________________________
Date:_____________________________________
Trucking Occupational Accident Application 01/01/16
Page 3 of 3
ADVERTISEMENT

Download "Truckers Occupational Accident Application Form - High Point Underwriters"

498 times
Rate
(4.7 / 5) 25 votes
Page of 3