OWNER OPERATOR / INDEPENDENT CONTRACTOR INSURANCE PROGRAM

General/Operations

Name of Motor Carrier: USDOT #:

Primary Address: # years in Business:

City: State: Zip: Tax ID #:

Telephone: ()- Fax: ()- Contact Person:

Commodities Hauled:

Description / General Freight / House Hold Goods / Hazmat / Other
Commodity
% Hauled

Other (please describe):

Type of Vehicles Used:

Type of Vehicle / Trailer / Flatbed / Tanker / Refrigerated
% Utilized
Type of Vehicle / Dump / Van / Double Trailers / Other
% Utilized

Other (please describe):

Does Motor Carrier haul, under its operating authority, any HAZMAT? Yes No

If yes, please provide a detailed description of material or chemicals percentages hauled:

Radius of Operations:

Radius0-50 Miles %50-200 Miles % Over 200 Miles %

Average Length of Haul MilesMaximum Length of Haul Miles

Do you haul Interstate or Intrastate? If both, please explain:

Terminal Locations (attach list if needed):

Driver Information

For the purpose of this coverage, one of the following definitions will apply to all Contract Drivers:

-Owner Operator (O/O) is an independent contract driver who owns (co-owns) the unit or leases (co-leases) long term in their name.

-Co-Driver (C/D) is an independent contract driver that drives with an owner operator at all times.

-Fleet Owner (F/O) is an independent contractor who owns or leases long term for his/her name, one or more power units and employs others to work for them.

-Fleet Driver 1099 (F/D1099) is paid on 1099 and operates a truck owned by an owner/operator who is leased to Motor Carrier

-Fleet Driver W-2 (F/DW2) is a driver who drives full-time for a Fleet Owner or Owner/Operator and is paid on a W-2.

Number of drivers:O/OC/DF/OF/D1099FDW2

Currently

Prior Year

2 Years Prior

Current Number of Drivers by State they live in. (must be completed or census attached):

O/O / C/D / F/O / F/D / O/O / C/D / F/O / F/D / O/O / C/D / F/O / F/D
AK / KY / NV
AL / LA / NY
AR / MA / OH
AZ / MD / OK
CA / ME / OR
CO / MI / PA
CT / MN / RI
DE / MO / SC
FL / MS / SD
GA / MT / TN
HI / NC / TX
IA / ND / UT
ID / NE / VA
IL / NH / VT
IN / NJ / WA
KS / NM / WI
WV
WY

W2 Fleet Information (multi-unit owners who employ additional drivers or single unit owners who do not drive):

Name of Owner / Number of Drivers / State of Domicile of Owner

Do Owner/Operators have any team drivers and/or Co-Drivers?

If yes, do they always work for the same Owner/Operator?

Do any Owner/Operators trip lease? If yes, whose authority will they be under?

Is Casual Labor used? Yes No If yes, please explain:

Who is responsible for the casual WC Coverage?

Percentage loading/unloading by driver: % Describe:

How many Employee/Company drivers?

Hiring Requirements

Provide details of minimum standards for contract drivers :

Minimum Age: Maximum Age:

Number of years over-the-road experience:

Maximum number of accidents permitted: (number) in past (number) years.

Maximum number of violations permitted: (number) in past (number) years.

Do you run MVRs: Yes No

Do you review Health History: Yes No

Describe any other criteria for qualifying independent contract drivers:

Will an Occupational Accident Plan (or Work Comp) be mandatory for all Owner/Operators for the Motor Carrier?

Yes No

What is the Average Annual Gross Settlement per Contractor?

What is the Average Annual Net Settlement per Contractor?

Coverage requested to be quoted.

  1. Occupational Accident Coverage:

Plan A:Plan B: Plan C: Plan G: Plan YC:

II. Non-Occupational Accident: Yes No

III. Motor Carriers’ Contract Liability: Yes No

Other Coverages/Policies:

Physical Damage/Personal ContentsYes No

Non-Trucking LiabilityYes No

Casual Labor Work Comp:Yes No

Fleet Owner’s Work Comp:Yes No

Corporate Work CompYes No

Passenger Accident Coverage:Yes No

Lease Information:

Does the lease agreement have a “Hold Harmless” statement? Yes No

Does the lease agreement have an option for Occupational Accident Coverage? Yes No

What year was the current lease agreement last updated/re-written?

In the past 3 years, has the Motor Carrier previously defended against a contract driver claiming employee status?

Yes No If yes, please provide a detailed explanation.

Safety Information:

Name of the person responsible for safety:

Number of years with the Motor Carrier: In loss prevention field:

Does the Motor Carrier provide training or safety meetings for independent contractors?

Yes No If yes, please describe.

For Occupational Accident Request:

-A list of all drivers showing address, date of birth, social security number, CDL license number and state. Fleet Drivers should be grouped under the fleet owner.

-A copy of the safety/training/maintenance programs and recruiting/hiring standards.

-A complete copy of the motor carriers lease agreement.

-A copy of current coverage.

-The losses for the previous 3 years.

For Contract Liability Request:

-When contract liability is being requested, motor carrier must provide a written and signed statement (email is acceptable), which states that “The submitted contract is a complete and accurate representation of the contract that each driver has signed and is on file with the motor carrier.”

For Physical Damage Request:

-Year, make, serial number, including the driver/owner’s name listed.

-Stated value with deductible.

-Current rate.

-Losses for the previous 3 years.

For Corporate Worker’s Compensation Request:

-Work Comp Losses for the past 5 years (valued within 90 days) with written description of loss greater than $25,000. Please mark the job title of the claimant and if the claimant is still with the motor carrier.

-Current year experience rating worksheet (MOD).

-Most recent year-end and interim Balance Sheet and Income Statement for the last 2 years (if available).

-Details of any changes in the risk that occurred in the last 12 months or a written statement that there were none.

-Copy of Safety program/details of loss control program.