Owner Operator Application printable pdf download

Owner Operator Application

Company Name ___________________________________________________

Please answer every question and fill in every blank. If the answer is non-applicable, please

write N/A. For the YES/NO questions, please circle the answer that is applicable.

1. Does your company currently use owner operators, lease purchase drivers, contract

drivers (that drive equipment other than your company owned trucks), or small fleet

company drivers? YES / NO If so, how many? __________

2. Is there a current Occupational Accident policy in place to cover each of these drivers?

YES / NO If yes, a copy of the current insurance coverage must be provided with this

application.

Is there current Contingent Liability coverage with adequate workers

compensation limits and a “pay on behalf of” basis in place in addition to the

Occupational Accident coverage? YES / NO If yes, a copy of the current insurance

coverage must be provided with this application.

3. Do any of these owner operators, lease purchase drivers, contract drivers (that drive

equipment other than your company owned trucks), or small fleet company drivers carry

their own current workers compensation coverage? YES / NO If so, The names of these

individuals must be provided on the sheet attached, along with a copy of the current

certificate of insurance.

4. Is any of the equipment used by these owner operators, contract drivers (that drive

equipment other than your company owned trucks), or small fleet company drivers

obtained by a lease/purchase agreement or of any form of financing provided by your

company or any other commonly owned company? YES / NO

If so, how many?

__________ The names of these individuals must be provided on the sheet attached.

5. Are any of these owner operators, lease purchase drivers, contract drivers (that drive

equipment other than your company owned trucks), or small fleet company drivers

through guaranteed financing arrangements with other companies? YES / NO

If so,

how many? __________ The names of these individuals must be provided on the sheet

attached.

6. Do any of these owner operators, lease purchase drivers, contract drivers (that drive

equipment other than your company owned trucks), or small fleet company drivers

participate in your company’s group health insurance? YES / NO If so, how many?

__________ The names of these individuals must be provided on the sheet attached.

Owner Operator Application