Fillable WC Specialty Trucking Supplemental Application 08.17 (All Risks, Ltd)

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WC Specialty Trucking Supplemental Application 08.17 (All Risks, Ltd)

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The WC Specialty Trucking Supplemental Application 08.17 (All Risks, Ltd) form is 2 pages long and contains:

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  • 19 check-boxes
  • 68 other fields

Country of origin: US
File type: PDF

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All Risks WC Specialties
Trucking Supplemental Application
Insured Name: _____________________________________________________________________________________________
Insured Web Address: _______________________________________________________________________________________
Insured FEIN:_________________________
PAYROLL/PREMIUM INFORMATION:
Policy Year
Payroll
Premium
4th Prior
$
$
3rd Prior
$
$
2nd Prior
$
$
1st Prior
$
$
Current
$
$
BUSINESS OPERATIONS (Check all that apply):
Common Carrier Contract Carrier Private Brokerage Exempt
______% Percentage of irregular routes: ______%
Percentage of regular routes:
Does insured have a MVR Program?
Yes No
Does driver have three or more violations or a major violation in the past three years? Yes No
Does insured principally operate as a freight forwarder or broker? Yes No
Yes No
Does insured engage in repossession operations, mobile home moving or hauling ammunitions, explosives,
hazardous materials, livestock, coal or logs/timber?
Are more than 10% of the driver’s independent contractors?
Yes No
What states are employees hired in? ____________________________________________________________________________
Please indicate all states traveled to: ____________________________________________________________________________
Frequency for each state traveled to: ____________________________________________________________________________
Length of Haul (Total Percentage Should Equal 100%)
51 – 200 Miles: _____ % _____ %
Under 50 Miles: _____ %
501 – 750 Miles: _____ %
751 – 1,000 Miles: _____ %
201 – 500 Miles:
Over 1,000 Miles:
_____ %
Max radius: _____ miles
WC Speciality – Trucking Supplemental Application – 08.17
Page 1 of 2
CARGO:
Is a Motor Carrier Identification report (MCS-150) attached? Yes No
Number of power units: _____ Number of drivers: _____
How are drivers paid: ________________ What percentage of payroll is based on overtime or double shift work: _____%
Identify the types of trucks used and the number used for each:
Flatbed: _____ Oversize: _____
Bobtail: _____ Dump: _____
Single Trailer: _____ Tanker: _____
Double Trailer: _____ Other (please explain): ________________________________
Average age of trucks: _____
Are there any Owner / Operators?
Yes No
*If yes, please provide # of Owner / Operators: ______
*Please attach proof of coverage.
Do drivers load or unload their trucks? Yes No
What percentage of trips involve overnight travel: _____%
What percentage of driving occurs between 12:00 am to 5:00 am: _____%
OPERATION QUESTIONS:
Does company have formal methods for training of drivers in the properties of their cargo and
in emergency procedures? Yes No
What percentage of vehicle maintenance is done by employees? _____%
Yes No
Yes No
Does the company have a formal and active fleet and safety program?
Are long haul drivers required to receive a medical exam every two years?
What percentage of your power units have tracking devices installed and utilized (i.e. GPS): _____%
** The undersigned attests that all information provided is both accurate and truthful. All information provided is subject to
verification by way of an underwriting survey or inspection. You must notify All Risks, Ltd. of any significant change in o
perations or
payroll. Terms of insurance coverage may be canceled for misrepresentation if information provided is inaccurate.**
Signature of Applicant:__________________________________________ Title: ________________________________
Print Name: ___________________________________________________ Date: _____________________
WC Speciality – Tru
cking Supplemental Application – 08.17
Page 2 of 2
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WC Specialty Trucking Supplemental Application 08.17 (All Risks, Ltd)

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Completed 15 July 2020

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