150 northwest point boulevard, 4th floor courier … insurance program application cr200 – rev....

CR200 – Rev. 2011/01/19

150 Northwest Point Boulevard, 4th Floor Elk Grove Village, IL 60007 Phone: (847) 700-8100 Fax: (847) 700-8116 www.avalonrisk.com

COURIER INSURANCE PROGRAM

APPLICATION

To obtain an insurance quotation, please answer all questions completely and return to your local Avalon office. If a

question does not apply to your business, please mark N/A (don’t leave blank). Where applicable, please complete an application for each covered location.

GENERAL INFORMATION Company Name (including DBAs): Address: City, State, ZIP: Contact name and title: Contact information: Phone: Fax: E-mail address: Website: Federal employer ID # or SS #: Corporate status: Corporation Partnership Individual Other, Please list: Corporate status: Are you publicly held? Yes No Years in business: Type of operation: Types of delivery you specialize in: DESCRIPTION OF OPERATIONS Type of Work Mileage Radius Additional Questions Route: % 0-100 miles % Residential business: % On-demand*: % 101-250 miles % Commercial business: % Rush: 2 Hours or less: % 252–300 miles % Largest city entered: Other: % More than 300 miles % States you deliver to: *One shot deliveries with no time constraints Are you a licensed freight broker? Yes No

Type of Messengers VEHICLES Gross Vehicle Weight Less than 10,000 lbs. 10,001-26,000 lbs. More than 26,000 lbs. Full-time/Part-time FT PT* FT PT* FT PT* No. of Independent Contractors No. of Employees/NOA Corp. Owned BIKERS & WALKERS Type: Bicycles Mopeds Motorcycles Walker – FT Walker – PT* No. of Independent Contractors No. of Employees/NOA Corp. Owned Do you have contracts with your independent contractors? Yes No *PT-Part-time is 20 hours or less per week on average or drivers earning 50% or less of average full-time driver.

Miscellaneous Do you store goods of others? Yes No Do you need a blanket waiver of subrogation? Yes No Do you have clients that require primary and non-contributory wording? Yes No

TOP FOUR CLIENTS Please list your four largest types of contracts/customers, the commodities being delivered and type of work: Type of Contract/Customer Commodities Hauled Type of Work Route On Demand Other Route On Demand Other Route On Demand Other Route On Demand Other

CR200 – Rev. 2011/01/19



APPLICATION

Please provide copies of the above policies. We can often obtain additional information from policies that is helpful in putting together our quotation. IN ADDITION TO THE COMPLETED APPLICATION WE MUST RECEIVE:

• Hard copy “loss runs” for all lines of coverage being quoted for the last 3 years. • Motor Vehicle Reports (MVRs) for all drivers (not more than 60 days old). • Policy declarations page for ALL independent contractors/employees driving their own vehicles on behalf of your company. • Your Bill of Lading or other shipping receipt. • Sample of Independent Contractor Agreement. • Copy of current states(s) certificate of authority (if applicable). • Copies of any written customer contracts, if applicable.

We are required to notify you of the following: “Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.”

GROSS ANNUAL REVENUE

Last Fiscal Year: $ Current Fiscal Year (estimate): $

What is the percentage of revenue generated by other delivery companies? % What is the total annual driver payroll (for non-owned and hired)? $

What is your annual dispatch payroll? $

What are the total annual settlements for IC drivers? $

Operating Authority

Federal Authority: Yes No Docket Number:

State Authority: Yes No States:

CURRENT INSURANCE INFORMATION Coverage Current Carrier Expiration Date Premium Property $ General Liability $ Owned Auto $ Hired/Non-Owned Auto $ Cargo $ Workers’ Compensation $ Umbrella $ Crime $ Other (list) $

Signature:

Printed Name: Title: Date:

CR200 – Rev. 2011/01/19



APPLICATION

PROPERTY SECTION Coverage Requested Limits (100% Replacement Cost Values) Building: $ Contents (including leasehold improvements): $ Personal Property of Others: (Complete Warehouse Supplement if storing customers’ property for more than 72 hours) $ Mobile Radios: $ Business Income/Extra Expense: Electronic Data Processing (EDP): Hardware: Data and Media: Extra Expense: Deductible ($1,000 minimum) Utility Services ($25,000 maximum) $

UNDERWRITING INFORMATION Type of building (Office, Warehouse, etc.): Year built: Total area of building: Percentage you occupy: % Wall construction: Masonry Brick veneer Frame Metal Roof construction: Wood deck Metal deck Number of stories: Basement: Yes No Describe other occupants if multi-tenant building (professional, manufacturing, etc.)

Fire protection (check all that apply): Sprinklers Extinguishers Standpipe Central station alarm Local alarm Other, please list:

CR200 – Rev. 2011/01/19



APPLICATION

WAREHOUSING SUPPLEMENT This must be completed if you have any kind of warehousing operation.

Address of warehouse: Total area (in cubic capacity or # of storage lots) of premises available for storage listed above: Total area of building: Area of building you occupy: If multi-tenant, please describe other occupancies: Building Description Number of stories: Basement: Yes No Exterior Wall Construction: Roof type: Floor type: Premises Protection Sprinklers: Yes No Central station alarm: Yes No Burglary included: Yes No Estimated total values in storage during the previous year (20 ): $

Maximum at any one time: $ Average at any one time: $ Do you issue a warehouse receipt? Yes No (If so, please attach a copy) If you answered “no” (to the above question), do you have any written agreements with customers as to who is responsible for what and how much? Yes No (If so, please attach a copy) How often do stored commodities turnover? (List by commodity): Gross receipts (from warehousing only) Last complete fiscal year (20 ) total: $ Estimated total for current year (20 ): $ Item(s) Maximum $ Value Average $ Value Food/perishables $ $ Furniture $ $ Electronics $ $ Television, radio/stereo, etc. $ $ Computer equipment/parts $ $ Office products (other than computer) $ $ Appliances (other than television, radio, etc.) $ $ Chemicals of any kind – describe (e.g. cleaning solvents, paints) $ $ Liquor, wine, spirits $ $ Auto parts $ $ Other (describe) $ $

CR200 – Rev. 2011/01/19



APPLICATION

COMMERCIAL GENERAL LIABILITY Please specify your general liability coverage and limits

COVERAGE LIMITS Annual General Aggregate: $ Each Occurrence: $ Products and Completed Operations: $ Personal & Advertising Injury: $ Employee Benefits Liability: $ Fire Damage Legal Liability: $ Medical Expense (per any one person): $ Deductible: $ RATING INFORMATION Warehouse/terminal payroll (if any – if not, leave blank): $ MISCELLANEOUS UNDERWRITING INFORMATION (Explain any “Yes” responses) Any other past or present partnerships or joint ventures that should be named? If so, list and describe on a separate sheet. Yes No

Any medical facilities provided? Yes No Any operations sold, acquired or discontinued in the last five years? Yes No Any watercraft owned, hired or leased? Yes No Any aircraft owned, hired or leased? Yes No Sponsor any athletic teams? Yes No Explanations:

Umbrella/Excess Liability Requested? Yes No Limit? $

($1,000,000.00 minimum. Higher limits are available, up to $25,000,000)

CR200 – Rev. 2011/01/19



APPLICATION

CARGO NOTICE Please note that this coverage is a “legal liability” contract versus a “first-party transit” coverage form. A legal liability form is used almost exclusively to provide coverage for common and contract carriers. While our form is broader than most, you should be aware of a few things:

• Coverage may be limited to what you state on a Bill of Lading or other form of delivery ticket (unless otherwise agreed to). • You may not be liable for certain events such as acts of God, neglect of the shipper, inherent vice or acts of the public enemy.

Therefore, coverage may not apply. • Contracts with customers should be closely reviewed to make sure that any liability you may have accepted is actually covered

by the policy. If there is any question at all about this coverage, please call us for clarification.

CARGO APPLICATION

COVERAGE LIMITS Standard Requested Any one loss, disaster or casualty: $25,000 $ Sub-limits In or on any one cargo conveyance: $25,000 $ Document reconstruction/face value/loss of interest: $25,000 $ Loss of market/use or delay, per occurrence: $25,000 $ Negotiable instruments, per occurrence: $25,000 $ At any one unscheduled terminal, per occurrence: $25,000 $ Deductible $1,000 (minimum)* $ Explain any special coverage needed: Do you have specific written contracts with customers? Yes No (If yes, attach copies) Do you use a bill of lading or any shipping receipt specifying a Limit of Liability? Yes No If yes, what is the limitation?

If you regularly transport packages, items or containers (freight) weighing more than 50 lbs.; we need a more detailed description, including what type of commodities, how often and how far. If you transport bank “proof work” (cancelled checks, cash letters, etc.) requiring Reconstruction and/or Face Value coverage, the Reconstruction/Face Value insurance questionnaire must be completed (one for each customer). *Please note there is an automatic minimum deductible of $2,500 (each occurrence) for losses involving electronics, pharmaceuticals and/or bank “proof work,” unless otherwise specified.

Commodities Carried PercentageOf Revenue

Max ValuePer Delivery

Commodities Carried

Percentage Of Revenue

Max ValuePer Delivery

Hazardous goods % $ Cash/negotiables % $ Non-negotiable financial documents % $ Perishables % $ Jewelry/precious metals** % $ Fine arts** % $ Pharmaceuticals % $ Animals % $ Electronics (complete supplemental app) % $ Fur % $ Other (misc. small package/envelopes) % $

If requested reconstruction limit is $100,000 or greater, the Reconstruction/Face Value supplement must be completed. Your customer will need to supply much of the required information. A $2,500 deductible applies to document reconstruction/face value/loss of interest. **Standard policy excludes coverage, however, if you do carry this type of property, please provide some additional detail and we will attempt to secure appropriate coverage, depending on the specific circumstances.

CR200 – Rev. 2011/01/19



APPLICATION

CARGO SUPPLEMENTAL APPLICATION – ELECTRONICS AND PHARMACEUTICALS Please answer each question below.

ELECTRONICS Specifically describe what you are transporting (e.g., PCs, computer components, industrial computerized equipment, etc.) Does the described property require any special handling due to size, weight or sensitivity? If so, specifically describe such requirements. Do you have written contracts with your customers limiting and/or accepting specific liability? If so, attach copies. Do you use a specific driver(s) for transporting this property? Are criminal background checks run?

PHARMACEUTICALS Specifically describe products being transported (over-the-counter, prescription, narcotics). Please estimate the percentage of narcotics being transported on a regular basis. Describe what security procedures are employed by your customer (shipper) and you such as sealed cartons, use of detailed manifests, background checks on drivers, vehicle alarms, etc. Do you have written contracts with your customers limiting and/or accepting specific liability? If so, attach copies. Will any of your pharmaceutical contracts involve line hauls? Yes No (If yes, answer below questions) How many? How often?

From where to where? Maximum value transported? $

Average value? $ Percentage of narcotics? %

For local distribution involving smaller vehicles (vans, pick-ups, etc.): How many vehicles are used on a regular basis? Normal mileage values?

Maximum value transported? $ Average value? $ Are any narcotics kept in your facility overnight? If yes, fully describe security measures:

Yes No

Please note: These types of shipments are the subjects of frequent claims. In order to ensure them at all we must have as much of the requested information as possible. If you do not presently have written contracts with your customers limiting liability in some way, you should. We would be glad to make suggestions in this regard. An automatic deductible of $2,500 per occurrence will apply to both electronics and pharmaceuticals shipments.

CR200 – Rev. 2011/01/19



APPLICATION

RECONSTRUCTION/FACE VALUE INSURANCE QUESTIONNAIRE Please complete one form for each bank/customer. All questions apply solely to the bank/customer below. Complete the application in as much detail as possible to obtain the proper coverage at the best possible rate.

Bank/Customer Name: Cities/States Involved: Requested Insurance Limits, each occurrence (dishonesty included) Reconstruction (including Loss of Interest): $ Yes No Reconstruction/Face Value Combined (including Loss of Interest): $ Yes No Face Value Only (including Loss of Interest): $ Yes No Total annual revenues derived from bank work: $ Total number of: Employee drivers: Independent Contractors: Type of cargo you transport, other than canceled checks: Branch Information Number of branches you pick up from: Average number of daily stops per branch: Distance between branches and processing center: Average: Max: Average number of bags per pickup per branch: Do you pick up deposits from bank customers? Yes No (If yes, answer below questions) Do the deposits include any cash? Yes No Maximum amount of cash in any one bag or from any one customer: $ At one time? $ List the type of bank customers from whom you pick up deposits (retail, office, etc.):

Does the bank have a photocopy procedure for checks? Yes No If yes, what is the value of checks the bank photocopies: All $1-$1,000 $1,001-$2,500 $2,501-$5,000 $5,001+Are routes for this bank dedicated? Yes No If not, how many banks are “co-mingled?” Are fire proof/resistant bags used? Yes No Do you use armed couriers? Yes No Are there halon canisters in bags? Yes No Are vehicles locked when unattended? Yes No Are drivers educated with the fact that there is nothing in the bags of intrinsic value? Yes No Is there a bar code or other electronic tracking system in place? Yes No Are bags secured by any type of locking device in vehicles? Yes No Are bags out of sight when transported? Yes No Do you have contractual arrangements with banks? (If yes, please attach copies) Yes No Do you have requirements that the bank must abide by? Yes No Methods of transportation: Cars, vans: % Air: % Driver Information Do you require two-way communication for each driver? Yes No Do you require: Uniforms for drivers? Yes No Picture IDs for drivers? Yes No Background checks on drivers? Yes No MVR checks on drivers? Yes No Does the bank have a check reconstruction procedure and team in place? Yes No (If so, briefly describe below) How and when does the bank make the determination that a destroyed/lost item(s) can’t be reconstructed and must be deemed a “face value” claim?

Provide the bank contact name and phone number for the person responsible for the reconstruction procedure in the event of a loss:

What is the bank’s lost bag protocol? Have you had any bank cargo losses in the past five (5) years? Attach a separate page if necessary, and provide a “hard copy” insurance company loss runs.

Yes No If yes, please explain

An automatic deductible of $2,500 per occurrence will apply to document reconstruction/face value/loss of interest.

Please also attach: List of all bank contracts you desire to cover under this policy and cargo losses for the last five years.

The undersigned declares that to the best of his/her knowledge and belief that the statements set forth herein are true.

Signature:

Print Name: Title: Date:

CR200 – Rev. 2011/01/19



APPLICATION

CRIME APPLICATION COVERAGE REQUESTED LIMITS DEDUCTIBLE ($1,000 min.)Employee dishonesty $ $ Forgery or alteration $ $ Money and securities (on/off premises) $ $

EMPLOYEEINDEPENDENT CONTRACTOR CENSUS (Indicate number of each) Employee drivers Full Time: Part Time: Independent contractor drivers Full Time: Part Time: Clerical/administrative employees Full Time: Part Time: Exclude owners/officers Full Time: Part Time: Other Full Time: Part Time: Total Full Time: Part Time:

MISCELLANEOUS UNDERWRITING INFORMATION (Relative to internal employee dishonesty) Is there a countersignature required on all checks? Yes No If “no”, what check amount requires a countersignature? $ Can the person who reconciles bank statements also deposit and/or withdraw money? Yes No Are financial audits performed? Yes No If so, how often? To your knowledge, do you transport money, negotiable securities, jewelry or precious metals? Yes No If yes, please explain:

CR200 – Rev. 2011/01/19



APPLICATION

BUSINESS AUTO APPLICATION

NON-OWNED/HIRED AUTOMOBILE COVERAGE • State of California: primary limits of $50,000.00 CSL or more must be carried by all employees or independent contractors.

We must receive copies of evidence of insurance with the application. • All other states: primary limits of $100,000.00 CSL must be carried by all employees or independent contractors. We must

receive copies of evidence of insurance with the application. Coverage is written on a contingent liability basis, excess of the driver’s primary insurance. Please note: Hired Auto Physical Damage coverage is NOT intended to cover an IC’s physical damage to his vehicle.

LIABILITY

COVERAGE LIMIT REQUESTEDBodily Injury/Property Damage (Owned & Non-owned) $1,000,000 *Personal Injury Protection (PIP) Statutory *Additional Personal Injury Protection (PIP) $ *Medical payments $ *Uninsured/Underinsured Motorists (UM/UIM) $

PHYSICAL DAMAGE*

Deductibles Comprehensive: $ Collision: $

OTHER COVERAGE OR ENDORSEMENTS

**Drive Other Car Liability? Yes No List individuals to be covered:

*This applies to company owned vehicles only **This applies to anyone (officer, employee, or independent contractor) driving company-owned vehicles who does not have their own personal auto policy. Please call us if there are any questions as to whom this may apply.

MISCELLANEOUS UNDERWRITING INFORMATION (Explain any “yes” response)

VEHICLES (Company-owned only) Number of company-owned or long-term leased vehicles: Is your garaging area fenced and lit? Yes No

Are company-owned vehicles customized or altered? Any special equipment installed? If yes, please specify:

Yes No

Are company-owned vehicles kept at drivers’ homes? Yes No Is personal use of company vehicles permitted? Yes No Are family members permitted to drive the insured vehicles? Yes No

Is there a preventative maintenance program for company-owned vehicles? If so, briefly describe:

Yes No

Are there regular vehicle inspections of company vehicles? Frequency: If you conduct vehicle inspections, how do you document?

Yes No

Have you been inspected by the Department of Transportation? If yes, what was the date of your most current inspection?

Yes No

CR200 – Rev. 2011/01/19



APPLICATION

BUSINESS AUTO APPLICATION - CONTINUED MISCELLANEOUS UNDERWRITING INFORMATION – CONTINUED

DRIVERS Do drivers wear a company uniform? Yes No Do you provide mobile equipment to the drivers? Yes No Do drivers load or unload vehicles? Yes No Do drivers operate the same vehicle each day? Yes No Do you lease drivers? Yes No (If yes, provide a copy of the lease contract) How are drivers paid? Hourly Salary Commission Other – please describe: Do you require your drivers to carry commercial insurance? Yes No If drivers are using their own vehicles, how do you monitor the existence of their insurance coverage? What limits are drivers using their own vehicles required to carry?

50 CSL 100 CSL 100/300/50 300 CSL Other (500,000 CSL required for vehicles 10,001 to 26,000 GVW; 1,000,000 CSL required for vehicles over 26,000 GVW) Any drivers under 21? (not eligible for insurance) Yes No What is the approximate annual driver turnover? % Do you carry any cargo that is considered hazardous material? Yes No (If yes, we will send you a Haz-Mat questionnaire)

DRIVER SELECTION Written application required? Yes No Written test required? Yes No Road test required? Yes No Interview by management? Yes No References checked? Yes No Police record checked? Yes No Background checked? Yes No Require 2+ years of U.S. driving experience? Yes No MVRs ordered on all drivers? Yes No If yes, list your MVR requirements: Are above items completed prior to employee/IC being allowed to drive? Yes No

SAFETY & COMPLIANCE For many companies, the owner(s) serve as Safety Coordinator, Accident Review, etc. Check “owner” if this applies to your company.Safety Coordinator appointed? Yes No Owner Risk Manager appointed? Yes No Owner Accident review committee? Yes No Owner Accident register maintained? Yes No Owner Driver training provided? Yes No Owner If yes, how is the program documented? Driver safety meetings? Yes No If so, how often: Do you have a driver orientation program? Yes No If yes, how is participation documented? Whether informal or sporadic, briefly describe what is done to promote safety: Do you keep maintenance files for all vehicles? Yes No Are accident records and files maintained? Yes No Do you have a drug test policy/program? Yes No Are drivers tested immediately after an accident? Yes No Do you randomly drug test employees after hiring? Yes No

MISCELLANEOUS Hours of operation: Name the type of dispatch system used: Employees or passengers transported? Yes No Do you have a motor carrier permit? Yes No For rush or on-demand business: Are conditions such as weather, time of day, distance, road construction, etc. taken into account when dispatching jobs with time constraints?

Yes No

Do you give time guarantees? If yes, what are the consequences of not meeting deadlines?

Yes No

Are penalties imposed on drivers for not meeting deadlines? If yes, please describe:

Yes No

Any armored car service? Yes No Do you do any pick-ups or deliveries to airports? If yes, do you have a ramp pass? Yes No

Yes No

Do you drive onto the tarmac? If so, at what airports?

Yes No

Are trailers utilized by any of your independent contractors or employees driving their own vehicles? If yes, how many and what type?

Yes No

CR200 – Rev. 2011/01/19



APPLICATION

DRIVER SCHEDULE For vehicles over 10,000 GVW, drivers must be at least 25 years old. For all other types, drivers must be at least 21 years of age.

Driver Type (I or E) FT/PT Name D.O.B.

Driver’s License No.

License State

State of Operation

Vehicle Driven (2)

Type of Vehicle (3)

(1) I = Independent Contractor E = Employee (2) D = Driver-owned vehicle C = Company-owned vehicle (3) Indicate the type of vehicle owned by the driver or which of the company-owned vehicles is operated by this driver. PPV = 10,000 GVW or less Light = 10,001 to 26,000 GVW (must have limits of $500,000 CSL)

Medium = 26,001 GVW and over (must have limits of $1,000,000 CSL)

CR200 – Rev. 2011/01/19



APPLICATION

OWNED FLEET VEHICLE SCHEDULE

Year Make Model VIN Garage Location

Value Comp (Y/N)

Coll (Y/N)

Radius GVW* 80% of Usage

* Gross Vehicle Weight – required only for vehicles in excess of 10,000 pounds

Vehicle Number:

Loss Payee Name: Loss Payee Address: Additional Insured Name: Additional Insured Address: Vehicle Number: Loss Payee Name: Loss Payee Address:

Additional Insured Name: Additional Insured Address:

CR200 – Rev. 2011/01/19



APPLICATION

NON-OWNED/HIRED AUTO PROGRAM AGREEMENT

This proactive program requires mutual participation between agent/broker and client. In order for us to obtain the best coverage and pricing available, we need your commitment to control losses. The following are mandatory requirements of the program:

1. The Primary Auto Insurance agreement must be executed for all drivers (those at policy inception and all new drivers) or similar

wording must be incorporated into your IC/Employment agreement.

• ALL drivers must carry at least $100,000 combined single limit OUTSIDE OF CALIFORNIA AND $50,000 WITHIN THE STATE OF CALIFORNIA. At the very least your driver contract should state something to the effect that “you should consult with an insurance professional to determine the amount and type of insurance best suited for your needs.”

2. You must obtain a Motor Vehicle Report (MVR) on each driver.

• You must obtain an MVR on every driver prior to him/her beginning work. • Our “point system” is enclosed. You must strictly enforce the system. Any drivers with 8 points or more will be put on formal

(written) probation with MVRs being run semi-annually. • You are required to report all driver changes, both independent contractors and employee drivers within 30 days.

3. You must have a system in place to track drivers’ primary insurance. Declarations pages are required. 4. We are asking for your signature to acknowledge the fact that you understand the Hired and Non-owned Coverage is being

written on a contingent basis. I, , representing , are (name & title) (courier company)

agreeing to the program requirements as stated above.

Authorized Signature: Date:

CR200 – Rev. 2011/01/19



APPLICATION

PRIMARY AUTOMOBILE INSURANCE AGREEMENT This agreement made and entered into this day of , by and between

, a corporation (herein referred to as (“company”) and

, an

(herein referred to as “Courier driver.”)

1. That Courier driver, in form satisfactory to Company, will have his/her own transportation and insurance, in the amount of (100/100/25 recommended)

2. Provide proof of insurance showing: Insurance company, policy number and expiration date, to company prior to Courier

driver’s start date.

3. Provide copy of Insurance Declaration page showing limits of policy to company within 30 days of driver start date.

4. Inform company of any changes to policy and provide company proof of Insurance renewal prior to policy expiration date. In Witness Whereof, the parties hereto have placed their hands and seals the day and year first above written.

Attest: Courier Driver

Witness: Date:

Courier Driver: Date: Attest: Company

Witness: Date:

Personnel Manager: Date:

CR200 – Rev. 2011/01/19



APPLICATION

DRIVER GUIDELINES

A Motor Vehicle Report (MVR) is a record of a driver’s past performance and is often a forecast of future performance. Violations and accidents which occur off the job are to be considered unless prohibited by state law as they are a reflection of a driver’s complete record and attitude of responsibility while operating a motor vehicle. All independent contractors and company-employed drivers must meet our driving standards. A current MVR will be required on all drivers including new and replacement drivers. Updated MVRs will be required annually upon renewal or as good underwriting judgment dictates. Due to the inconsistencies between the State DMVs and how they allocate points, we have developed our own standard point system. We utilize a three-year history on the driver’s experience. A maximum of 11 points is acceptable.

• Any driver with 8 – 11 points will be placed on probation • Any driver exceeding 11 points is not eligible

Points are determined as follows:

• Speeding – 5 points • Moving Violations other than speeding – 4 points • At-Fault Accidents (All accidents will be assumed at-fault without explanation.) – 6 points

Major violations are unacceptable (see below) – Any driver with a major violation within the past three years will be excluded from coverage. Major violations include, but are not limited to:

• Driving while intoxicated or under the influence of intoxicating liquor or any drug • Disregarding or evading a police officer • Driving with a suspended/revoked license due to driving record • Driving on the wrong side of the road • Failure to comply with implied consent law • Felony involving a motor vehicle • Hit and run or leaving the scene of an accident • Homicide or vehicular assault • Illegal passing resulting in an accident • Manslaughter with or without gross negligence • Possession of a controlled substance • Reckless driving, drag racing or speed contest • Passing a school bus which has its “stop” displayed

CR200 – Rev. 2011/01/19



APPLICATION

WORKERS’ COMPENSATION ALERT INDEPENDENT CONTRACTOR OPERATIONS

Most of you carry Workers’ Compensation on your employees, depending on the minimum number of employees required to be covered by the Workers’ Compensation laws in your state. These employees usually consist of administrative and clerical people, maybe dispatchers and sales people. However, when it comes to your IC drivers, many of you rely solely on written agreement with the IC’s to let you off the hook if an IC is injured and attempts to make a claim. Assuming you have a Workers’ Compensation policy, the carrier will have to step up and defend and pay a claim, if an IC successfully sues and is deemed to be an employee. Unless you have a written agreement with the carrier that they will not audit IC driver payroll for premium purposes, you could be in for a rude awakening! The chances of such an agreement are slim. The carrier can legally go back demanding drivers’ premium for three years! And they will not limit the payroll to the one driver who was injured. If you never have a driver try to make a claim, you may conceivably avoid a devastating audit forever. However, keep in mind there does not necessarily have to be a claim to trigger an audit. An insurance carrier has the contractual right to physically audit your payroll. Over the years, we have heard many of you state that IC’s are not required to carry Workers’ Compensation in your state. True enough, in most all jurisdictions. However, if they are injured badly enough and decide they are now an employee (and with an attorney’s help, this is not that difficult), they are under the Workers’ Compensation law! Don’t make the mistake of ignoring this potentially devastating situation. There are reasonably priced solutions. An alternative may be to calculate what the annual driver premium would be and create a reserve. The point is, don’t just ignore the issue. Take some definitive action. Talk to us about this. That’s what we’re here for!

CR200 – Rev. 2011/01/19



APPLICATION

WORKERS’ COMPENSATION APPLICATION

State Class Code Duties/Job Description Number of Employees Estimated Payroll

Current Experience Modification: Federal Employer Identification Number: Are partners, Owners, Officer to be included? Yes No Are partners, Owners, Officers to be excluded? Yes No List each partner/owner/officer, including birth date, duties and payroll:

1. 2. 3. 4. 5. Current Workers’ Compensation Policy Information: Insurance Carrier: Policy Number: Policy Period: Employer’s Liability Limits:

CR200 – Rev. 2011/01/19



APPLICATION

WORKERS’ COMENSATION APPLICATION – CONTINUED GENERAL INFORMATION Please provide all required details for “yes” responses in the space provided next to the question

General Questions Answers Explanations 1. Does applicant own, operate or lease aircraft/watercraft? Yes No 2. Any exposure to flammables, explosives, caustics, fumes? Yes No 3. Any exposure to radioactive material? Yes No 4. Any work performed underground or above 15 feet? Yes No 5. Any work performed on barges, vessels, docks, bridge over water? Yes No 6. Is applicant engaged in any other type of business? Yes No 7. Are subcontractors used? (If yes, give % of work subcontracted) Yes No 8. Any work sublet without certificates of insurance? Yes No 9. Is a formal safety program in operation? Yes No 10. Any group transportation provided? Yes No 11. Any employees under 16 or over 60 years of age? Yes No 12. Any part-time or seasonal employees? Yes No 13. Is there any volunteer or donated labor? Yes No 14. Are there any employees with physical disabilities? Yes No 15. Do employees travel out of state? (If yes, indicate state(s) of travel and frequency) Yes No

16. Are athletic teams sponsored? Yes No 17. Are physicals required after employment offers are made? Yes No 18. Any other insurance with this insurer? Yes No 19. Any prior coverage declined/canceled/non-renewed (last 3 years)? Yes No 20. Are employee health plans provided? Yes No 21. Is there a labor interchange with any other business or subsidiary? Yes No 22. Do you lease employees to or from other employers? Yes No 23. Do any employees predominantly work at home? If yes, # of employees Yes No

24. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)

Yes No

25. Do any employees perform work for other businesses or subsidiaries? Yes No 26. Any tax liens or bankruptcy within the last five years? Yes No 27. Any undisputed and unpaid workers’ compensation premium due from you or any commonly managed or owned enterprises? If yes, explain including entity name(s) and policy number(s).

Yes No

Please use the below section for additional space to explain “yes” responses

Question Number Additional Space

CR200 – Rev. 2011/01/19



APPLICATION

INSURANCE CHECKLIST

Below is a list of usually available coverage (not all-inclusive), some of which will be quoted to you per the application(s) completed:

Property (Building & Contents) Automobile Business Income Employee Dishonesty Extra Expense Money & Securities Flood Depositor’s Forgery Earthquake General Liability Electronic Data Processing Fiduciary Liability Signs Employee Benefits Liability Plate Glass Stop Gap Liability Cargo Liability Workers’ Compensation/Employers Liability Transportation Umbrella/Excess Liability Ocean Cargo Directors & Officers Liability Valuable Papers Employment Practices Liability Accounts Receivable

If you are interested in additional coverage, further explanation and/or a quotation, please call or write us with your request.

150 northwest point boulevard, 4th floor courier … insurance program application cr200 – rev....

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