Truckers Occupational Accident Insurance Questionnaire Form

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Truckers Occupational Accident
Insurance Questionnaire
A m e r i c a n I n t e r n a t i o n a l C o m p a n i e s
®
Submission Date: _______________
Quote Due Date: _______________
RISK INFORMATION
Name: ______________________________________________________________________________________________
Street Address: _______________________________________________________________________________________
City: ___________________________________________ State: ____________ Zip Code: ___________________
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)
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)
Telephone Number: ______________________________ Fax Number: ____________________________________
Nature of Business: _______________________________
1. Federal Employer Identification Number (FEIN): __________________________________________________________
2. Describe and give percentages of specific commodities hauled. (Avoid general terms.) Please use a separate sheet, if necessary.
Commodity
Total
Percent Hauled
100%
3. What percentage of total truck loads are manually loaded or unloaded?
Manually Loaded: ________% Manually Unloaded: ________% No trucks are manually loaded or unloaded.
4. What percentage of vehicles are: Box: _____%
Flatbed: _____%
Tanker: _____%
Dump: _____%
Other: _____%
Describe types and quantity of vehicles marked as “Other”: _________________________________________________
5. Number of leased independent owner-operators/contract drivers: _____________________________________________
6. In which states are your owner-operators and contract drivers domiciled? (Attach a separate sheet, if necessary.)
State
Number of Drivers Domiciled
7. What percentage of your owner-operators’/contract drivers’ trips are: 1–50 Miles: _____% 51–200 Miles: _____%
Over 200 Miles: _____%
8. Is there any exposure to flammables, explosives, caustics, or fumes?
Yes
No If Yes, please explain and provide
percentage of exposure: _______________________________________________________________________________
9. Is there any exposure to radioactive materials?
Yes
No If Yes, please explain and provide
percentage of exposure: _______________________________________________________________________________
10. Is a formal safety program in operation?
Yes
No If Yes, please describe. If No,
please explain: _____________________________________________________________________________________
11. Are pre-employment physicals required?
Yes
No
12. Describe your new-driver screening procedures for hiring leased owner-operators/contract drivers:____________________
__________________________________________________________________________________________________
13. Please complete the chart below.
Valuation Date: ____________________________
Number of Insured
Owner-Operator
Term
Earned Premium
Owner-Operators
Monthly Premium
Incurred Losses
Number of Losses
14. Have you had Occupational Accident Insurance or Workers’ Compensation coverages on your leased owner-operators/
contract drivers previously?
Yes
No If No, please explain how on-the-job injuries were covered: _________
__________________________________________________________________________________________________

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