Truckers Occupational Accident Insurance Questionnaire Form Page 3
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4Contingent Liability/Motor Carrier Protection
T h e A I G L i f e
Program Questionnaire
C o m p a n i e s ( U. S . )
(Addendum to Truckers Occupational Accident Insurance Questionnaire)
Choose Appropriate Box:
Contingent Liability Program
Motor Carrier Protection Program (MCPP)
Both
1. Motor Carrier Name: ________________________________________________________________________________
2. Has any prior Workers’ Compensation, contingent Workers’ Compensation, contingent liability, or similar coverage
been declined, canceled, or non-renewed in the past three years?
Yes
No If Yes, please explain: _________
____________________________________________________________________________________________________________
3. Please provide information on your current employee Workers’ Compensation policy, contingent Workers’
Compensation policy, contingent liability policy, or similar coverage. Please specify which policy.
Insurer Name: ____________________________________________________________________________________________________
Policy Number: _________________________________ Term: _____________________________________________
State of Domicile: _______________________________ Type of Policy: _____________________________________
If Workers’ Compensation, please provide the Experience Modification Factor: _________________________________
4. Have you ever experienced a loss under Workers’ Compensation, contingent liability, or similar coverage where an
owner-operator or contract driver has become an employee?
Yes
No If Yes, please give details of each loss.
(Attach a separate sheet, if necessary.)
Date
Description
Amount of Loss
1)
2)
3)
4)
5)
5. Have you been cited for any Occupational Safety and Health Administration (OSHA) violations in the past five years?
Yes
No If Yes, please provide details: _____________________________________________________________________
6. COVERAGE LIMITS
Coverage A (Benefits)
Coverage B (Employer’s Liability)
Statutory Workers’ Compensation
$100,000 Bodily Injury by Accident (Each Accident)
Other (not available with MCPP):_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
$500,000 Bodily Injury by Disease (Policy Limit)
________________________________________________________________
$100,000 Bodily Injury by Disease (Each Employee)
________________________________________________________________
Other
________________________________________________________________
$___________ Bodily Injury by Accident (Each Accident)
________________________________________________________________
$___________ Bodily Injury by Disease (Policy Limit)
________________________________________________________________
$___________ Bodily Injury by Disease (Each Employee)
________________________________________________________________
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