Occupational Accident Insurance Application

Occupational Accident Insurance Application – 05.18

QUESTIONNAIRE – Occupational Accident Insurance

NOTE: There are six sections to this questionnaire. All sections must be completed for questionnaire to be accepted. Questionnaire must be signed.

Submission Checklist

Copy of current Occupational Accident Insurance Policy

Copy of current Contingent Liability Insurance Policy

Loss runs (3-5 years)

Historic unit counts to match the loss run term

Explanation of losses >$25,000

Owner Operator Lease Agreement

Equipment Lease Agreement (if applicable)

Explanation of SMS scores over threshold/copy of safety manual

Driver census listing: Name, Address, DOB

POLICY EFFECTIVE DATE: QUOTE DUE DATE:

Motor Carrier Name*:

Street Address:

City: State: Zip:

USDOT Number:

Contact Person: Title:

Telephone: Email Address:

*If this Questionnaire is being completed for more than one carrier or the above carrier has more than one terminal location, please provide names/addresses below (Attach a separate sheet, if necessary):

Name Address

1.

2.

3.

SECTION I: Motor Carrier Information

1. How many years has the motor carrier been in business?

2. Total number of Independent Contractors:

3. How many Independent Contractors are to be covered under this program?

4. Does the motor carrier haul hazardous materials? Yes No

a. If yes, what percent of TOTAL loads are hazardous materials?

b. Provide the percent of TOTAL loads that are: Flammable Fuel Caustic Poisonous Explosive

5. What is the radius of operation? 0-50 miles 51-200 miles 201+ miles

6. What do drivers haul?

7. What percentage of equipment is:

a. If other, please describe:

b. Is equipment leased from the motor carrier or third party?

8. Do the drivers load or unload? Yes No

a. If yes, what percentage of time?

9. What percentage of the Independent Contractor hauls is less than load (LTL)?

10. Are casual laborers or helpers used? Yes No

a. If yes, where and how?

b. Do laborers/helpers require Occupational Accident insurance? Yes No

SECTION II: Driver Information

Minimum Standards for Independent Contractors:

1. What is the minimum age? What is the maximum age?

2. Is training provided for Independent Contractors? Yes No

a. If yes, please describe:

3. Describe any other criteria for qualifying Independent Contractors:

Indicate number of Independent Contractors by residence:

Owner Operator (OO) is an independent contractor who owns and drives the truck unit. Contract Driver (CD) is an independent contractor who is paid on a 1099, but drives the truck for another owner. Fleet Owner (FO) is an independent contractor who has more than one truck under contract to the trucking firm. Fleet Driver (FD)* is a W-2 paid employee driver of a contracted fleet owner. *Fleet Drivers are not eligible for Occupational Accident coverage and must be covered under Workers’ Compensation.

SECTION III: Insurance Plan and Requested Coverage

1. What is the target rate for Occupational Accident Insurance?

2. Is a sponsored Occupational Accident coverage currently in force? Yes No

a. If yes, please provide:

3. Why is this account out to market?

A. OCCUPATIONAL ACCIDENT BENEFITS

AD&D

Death and Dismemberment Benefit $150,000 $200,000 $250,000 $300,000 Other $

MEDICAL

Accident Medical Expense Benefit $300,000 $500,000 $1,000,000 Other $

Maximum Benefit Period 52 weeks 104 weeks

Benefit Waiting Period 7 Days 14 Days

DISABILITY

Temporary Total Disability Benefit $400 $500 $600 Other $

Permanent Total Disability Benefit* $400 $500 $600 Other $

* Claimant must receive Social Security Disability Award to qualify for Permanent Total Disability Benefits

B. NON-OCCUPATIONAL ACCIDENT BENEFITS

1. Do you wish to add Non-Occupational Accident Benefits to this policy? Yes No

a. Death and Dismemberment Benefit $7,500 $10,000 $15,000 Other $

b. Accident Medical Expense Benefit $5,000 $10,000 Other $

C. OPTIONAL COVERAGES

1. Please indicate if you wish to add the following coverages to this policy:

a. Hernia $5,000 $10,000 Other $

b. Hemorrhoid $5,000 $10,000 Other $

c. Passenger Accident $10,000

d. Occupational Disease/Cumulative Trauma $5,000 $10,000 Other $

D. CONTINGENT LIABILITY COVERAGE

1. Do you wish to add Contingent Liability coverage to this policy? Yes No

SECTION IV: Contingent Liability Information (if applicable)

1. Is there currently a Contingent Liability policy or similar coverage in place? Yes No

a. If yes, what is the name of the Insurance Company?

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

a. If yes, please explain:

3. Have you ever experienced a loss under Workers' Compensation, Contingent Liability or similar coverage where an Owner-Operator or Contract Driver has sued for employee status? Yes No

a. If yes, please give details of each loss (Attach a separate sheet, if necessary):

4. Do the drivers sign Independent Contractor agreements? Yes No

5. Is the Independent Contractor responsible for providing the truck? Yes No

6. Can the Independent Contractor receive assignments/opportunities from a freight broker or other motor carriers? Yes No

Contract Liability Coverage Limits:

Part One of the policy applies to Contract Liabilities incurred as the result of the Workers’ Compensation laws. Part A Limits: Statutory Limits each person each Accident; Statutory Limits each person each Occurrence

Employers Liability Insurance: Part Two of the policy limits are: Bodily Injury by Accident $1,000,000 /Policy Limit; Bodily Injury by Disease $1,000,000 /each Accident; Bodily Injury by Disease $1,000,000 /each Person

SECTION V: Loss Control information

1. Name of Safety Manager:

2. Number of years experience in Loss Prevention:

3. Number of years working with this motor carrier:

4. Provide a brief description of the Safety Program currently in place (i.e. electronic logbooks, EOBRs, etc.):

SECTION VI: Producer Information

1. Are you the incumbent broker/broker of record? Yes No

2. Are you licensed in the motor carrier’s state (if there are multiple terminals, this refers to the motor carrier’s address registered with the DOT)? Yes No

3. Is the license for: Accident & Health Property & Casualty Both

On Behalf of Motor Carrier: