Independent Contractors Questionnaire

Independent Contractors Questionnaire

Please complete the following questionnaire to apply.
Motor Carrier Information
Motor Carrier Name
DOT Number
MC Number
Federal Tax ID Number
Motor Carrier Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Motor Carrier Contact
Motor Carrier Contact Phone Number
Please enter a valid phone number.
Motor Carrier Contact Email Address
example@example.com
Motor Carrier Website
Years in Business
Subsidiaries / Affiliates to be covered?
Has Motor Carrier filed for bankruptcy protection within the last 5 years?

YesNo
Has Motor Carrier ever had insurance coverage cancelled or non-renewed within the last 5 years?

YesNo
Coverages Requested

Occupational AccidentContingent LiabilityPhysical DamageNon-Trucking Liability
Requested Effective Date

MonthDayYear
Date
Date Quote Needed

MonthDayYear
Date
Operations
What is the Radius of Operations?
0-50 miles
50-200 miles
201-500 miles
501+ miles
Equipment
Type of Vehicle (select all that apply)

Auto TransportBox/Straight TruckContainerDry VanFlatbedTankerDumpRefrigeratedStep DeckTandemOther
Other
Please list each percentage of vehicle type selected above
Commodities
Commodities Hauled (select all that apply)

Agricultural/Farm SuppliesBeveragesBuilding MaterialsChemicalsCoalCommodities/Dry Bulk/AggregateConstructionDrayage/Intermodal ContainerDrive Away/Tow AwayFresh ProduceGarbage/RefuseGeneral FreightGrain/Feed/HayHazmatHot ShotLarge Machinery/ObjectsLast MileLiquids/GassesLivestockLoggingLumberMetal sheets, coils, rollsMobile HomesMotor VehiclesOil field EquipmentPaper ProductsRefrigerated FoodUS MailUtilities
Please provide the percentage of each commodity hauled
Please upload list of commodities hauled

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Agreements
Do all Independent Contractors sign lease agreements?

YesNo
Please upload IC lease agreements

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Does motor carrier have a lease to purchase program (agreement cannot be directly with the motor carrier)

YesNo
Please upload lease to purchase agreement

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Driver & Safety Information
Drivers
Minimum Age
Maximum Age
Maximum number of accidents permitted: # accidents in past yearsyears.
Maximum number of violations permitted: # violations in past yearsyears.
Are MVRs checked prior to hiring?

YesNo
How often thereafter?
Describe your driver screening process for hiring Independent Contractors.
Is there a driver orientation and/or training program?

YesNo
How are drivers compensated?

% of loadMileageHourly
Is there a driver incentive program?

YesNo
If yes, provide description of the program
Safety
Is there a formal safety program?

YesNo
Please upload the safety manual

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How often are safety meetings held?
Are drivers required to attend safety meetings and trainings?

YesNo
Is there a Driver Safety Incentive Program?

YesNo
Explain
Is there a formal vehicle maintenance program?

YesNo
How often is routine maintenance performed?
Does the Motor Carrier conduct inspections?

YesNo
Are maintenance records kept on individual vehicles?

YesNo
Do you utilize technology for loss prevention?

YesNo
Is Technology mandated on all vehicles?

YesNo
Describe Technology used (Telematics, ELDs, Cameras, etc.)
Safety Director Name
Safety Director Phone Number
Please enter a valid phone number.
Safety Director Email
example@example.com
Years of experience of Safety Director
Occupational Accident
Do all Independent Contractors own their vehicles?

YesNo
If no, please explain any exception
Do any Independent Contractors operate company-owned units?

YesNo
If yes, please explain the circumstance
Do the drivers load or unload?

YesNo
If yes, what percentage of time?
Do the drivers Bind or Tarp?

YesNo
Indicate number and type of drivers by state of residence.

OO = Owner Operator is an Independent Contractor (paid on a 1099) who owns/leases and drives the truck.

CD = Contract Driver is an Independent Contractor (paid on a 1099) who drivers the truck for another owner.

	OO	CD
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming

How many drivers are currently covered under the Occupational Accident program?
Does motor carrier authorize passengers of Owner Operators?

YesNo
If yes, how many?
Do you allow Owner Operators to utilize Casual Laborers?

YesNo
Do you utilize company employed Drivers?
If yes, how many?

Occupation Accident Historic Driver Count

	Policy Term	Driver Count
1.
2.
3.
4.
5.

OR Upload 3-5-year historic driver counts to match the loss run terms.

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Upload Driver List including name, address, DOB, DOH, Years of Experience.

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Occupational Accident Loss Experience Summary (Current and Historical for past 3-5 years)

	Policy Term	# of Claims	Paid	Reserve	Total Incurred
1.
2.
3.
4.
5.

Upload Occupational Accident carrier issued loss runs – Currently valued for the last 3-5 years.

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Upload current Occupational Accident Policy along with expiring rates.

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Current Occupational Accident Driver Rate
Coverage Options
Accidental Death and Dismemberment (AD&D)

$200,000$250,000$300,000Other
Other Amount
Accident Medical Expense (AME) Benefit Amount

$500,000$1,000,000$2,000,000Other
Other Amount
Temporary Total Disability (TTD) Per Week

$500$600$700Other
Other Amount
Continuous Total Disability (CTD) Per Week

$500$600$700Other
Other Amount
Combined Single Limit Per Insured

$1,000,000$2,000,000Other
Other Amount
Aggregate Limit Per Occurrence

1,000,000$2,000,000Other
Other Amount
Comission Requested
Contingent Liability
Is there currently a Contingent Liability policy in place?

YesNo
Has any prior Workers' Compensation, Contingent Liability or similar coverage been declined, canceled or non-renewed in the past three years?

YesNo
If yes, please explain
Have you ever experienced a loss under Workers' Compensation, Contingent Liability or similar coverage where an Independent Contractor or Contract Driver has sued for employee status?

YesNo
If yes, please give details of each loss
Can Independent Contractor receive assignments/opportunities from a freightbroker or other motor carriers?

YesNo

Contingent Liability Loss Experience Summary (Current and Historical for past 3-5 years)

	Policy Term	# of Claims	Paid	Reserve	Total Incurred
1.
2.
3.
4.
5.

Upload Contingent Liability carrier issued loss runs – Currently valued for the last 3-5 years

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Upload current Contingent Liability Policy along with expiring pricing

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Current Contingent Liability Annual Premium
Coverage Options
Limits Requested

$1,000,000$2,000,000Equivalent to Statutory Benefits
Employers Liability
Injury by Accident (each covered person per accident)

$100,000$500,000$1,000,000
Injury by Disease (policy limit)

$100,000$500,000$1,000,000
Injury by Disease (each covered person)

$100,000$500,000$1,000,000
Comission Requested
Physical Damage
List Terminal, Plant or Warehouse Locations
Type of Security at Locations
Concentration of Value (%) at Locations
Does the motor carrier have an in-house shop?

YesNo
Type of repairs

MinorMajorBody

Physical Damage Historic Equipment Count Summary (Current and Historical for past 3-5 years)

	Policy Term	Trucks	Trucks TIV	Trailers	Trailer TIV
1.
2.
3.
4.
5.

OR Upload 3-5-year historic equipment count and TIV to match the loss run terms.

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Upload Equipment List (including Year, Make, Model, VIN, State, EquipmentValue).

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Physical Damage Loss Experience Summary (Current and Historical for past 3-5 years)

	Policy Term	# of Claims	Paid	Reserve	Total Incurred	Deductible
1.
2.
3.
4.
5.

Physical Damage Loss Experience Summary (Current and Historical for past 3-5years: # of claims, paid, reserved, total incurred, deductible).

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Upload Physical Damage carrier issued loss runs – Currently valued for the last 3-5 years.

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Upload current Physical Damage Policy along with expiring rates.

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Current Physical Damage Rate
Coverage Options
Deductible

$500$1,000$1,500$2,000$2,500$5,000Other
Other Amount
Towing Limit
Deductible BuyBack

YesNo
Deductible BuyBack Limit
Retained BuyBack Limit
Loan/Lease Gap

YesNo
Extended Repair Time

YesNo
Extended Repair Time Limit
Truck Rental

YesNo
Special Equipment

YesNo
Special Equipment Limit
Special Equipment Deductible
Personal Contents

YesNo
Personal Contents Limit
Personal Contents Deductible
Other Coverages
Commission Requested
Non-Trucking Liability
Total number of units to be covered

Non-Trucking Liability Historic Unit Count

	Policy Term	Units
1.
2.
3.
4.
5.

OR Upload 3-5-year historic unit count to match the loss run terms.

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Non-Trucking Liability Loss Experience Summary (Current and Historical for past 3-5 years)

	Policy Term	# of Claims	Paid	Reserve	Total Incurred
1.
2.
3.
4.
5.

Non-Trucking Liability Loss Experience Summary (Current and Historical for past3-5 years: # of claims, paid, reserved, total incurred, deductible).

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Upload Non-Trucking Liability carrier issued loss runs – Currently valued for thelast 3-5 years.

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Upload current Non-Trucking Liability Policy along with expiring rates.

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Current Non-Trucking Liability Rate
Coverage Options
Combined Single Limit

$500,000$1,000,000Other
Other Amount
Minimum statutory UM/UIM/PIP limits will be provided. If other limit is required for UM/UIM/PIP, list limit and explain reason for request
Additional Coverage Requested
Comission Requested
Agency Information
Agency Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By submitting this application, you declare that all information provided is accurate and complete, and you authorize the insurance company to verify this information and obtain additional reports about your history. You acknowledge that any misrepresentation or omission may result in denial of coverage or termination of any policies issued based on this application. Please confirm this application is accurate and is completed to the best of your ability.*

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Name
Date*

MonthDayYear
Date
Should be Empty:

Independent Contractors Questionnaire

Motor Carrier Information

Operations

Equipment

Commodities

Agreements

Driver & Safety Information

Drivers

Safety

Occupational Accident

Coverage Options

Contingent Liability

Coverage Options

Employers Liability

Physical Damage

Coverage Options

Non-Trucking Liability

Coverage Options

Agency Information