Truckers Occupational Accident Application

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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
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