Insured Proposed Effective Date Policy Expiration Date

Contact Person/Title Federal Tax ID

Telephone Number Fax Number E-Mail

Mailing Address

Years in Business No. of Locations Operations Outside of State?

☐Yes ☐No

Terminal Number/Address

Officer Name Title % of Stock Included/Excluded

Description of Operations

15760 Ventura Blvd. Suite 1450 Encino, CA 91436 License Tel: Fax:

Are you a FedEx Subcontractor?

☐Yes ☐No

Is your current coverage through Marsh/Protective? ☐Yes ☐No

Driving records checked annually?

☐Yes ☐No

Are Routes Established?

☐Yes ☐No

Max Daily Driving Radius: __________

Radius of Travel by percentage (total must equal 100%):

<50 mi. _______ 50-200 mi. _______

201-500 mi. _______501-1,000 mi. _______

>1,000 mi. _______

Will drivers load & unload their trucks? ☐Yes ☐No

Max Lifting Exposure: _________ lbs.

Average weight of packages: ____ lbs.

Number of vehicles? ______

All trucks equipped with lift gates?

☐Yes ☐No

Is vehicle maintenance outsourced?

☐Yes ☐No

Number of drivers? ______

Are drivers equipped with hands free talking devices while en route? ☐Yes ☐No

Do you only use Independent Contractors? ☐Yes ☐No

Average Wage? ___________

Formal driver safety program? ☐Yes ☐No

Are monthly safety meetings held?☐Yes ☐No

Safety Director / Risk manager employed? ☐Yes ☐No

If yes, Name:____________________

Do you offer group health plans for your employees? ☐Yes ☐No

If yes, carrier:__________________

Any use of armored vehicles?

☐Yes ☐No

Is there a formal vehicle maintenance program? ☐Yes ☐No

Number of independent owner/operators: _____

Any height exposure on any device in excess of 12 ft: ☐Yes ☐No

Any hazardous material hauling?

☐Yes ☐No

Does the risk have proper safety protocols regarding material handling? ☐Yes ☐No

Pre-hire drug testing?

☐Yes ☐No

Post-accident drug testing?

☐Yes ☐No

Hours of Operation: __________

Any employee shifts exceeding 12 hours: ☐ Yes ☐ No

Are drivers with 3 or more violations or 1 at fault accident prohibited from driving?

Yes No

Are drivers with any 2 point violation, reckless driving or DUI in the last 5 years prohibited from driving?

Yes No

Enrolled in the Employer Pull Notice Program?

Yes No

TRUCKING APPLICATION WORKERS COMPENSATION

Class Code Payroll Number of Full-Time Number of Part-Time

Payroll Information Premium Information

Current year

Prior year

Prior year

Prior year

Prior year