Truckers Occupational Accident Application Page 2
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3Driver 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
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