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
