Trucking Supplemental Trucking Supplemental Description of Operations, Hiring, Employment & Safety CharacteristicsApplicant NameProposed Effective DateFEINCompany WebsiteDescription of OperationsMisc. (Explain any gaps in coverage, cancellations, significant fluctuations in payroll, etc.)Hiring Practices Check Yes ONLY if Applicable to 75%+ of LaborWritten ApplicationYESNOWritten Job DescriptionYESNOBackground/Reference CheckYESNOPre-Hire Drug TestingYESNOPre-Hire Physical Fitness TestYESNOMVR CheckYESNOInterviewYESNORoad TestYESNOFMCSA Pre-Employment ScreenYESNOSafety Practices Check Yes ONLY if Applicable to 75%+ of LaborFormal Injury & Illness Prevent. PlanYESNOFormal Return to Work PlanYESNOQuarterly (or More) Safety MeetingsYESNOQuarterly (or More) Safety TrainingYESNOSafety Incentive PlanYESNOClean Roadside Inspection IncentiveYESNOElectronic LogbooksYESNOGPS Devices (Installed & Used)YESNOManagement Practices, Loss Control, Claims Handling & BenefitsIs the ownership active in the day-to-day operations of the company?YESNOIs there a full-time risk/safety manager employed whose job is 50%+ safety related?YESNOIs there a formal and random drug testing program for all employees?YESNOIs there a formal post-accident drug testing program for all workplace injuries?YESNOUpon termination are personnel files documented for any potential workplace injuries?YESNOIs there a formal accident investigation and claims reporting process?YESNODo more than 50% of employees receive group health through you that is 50%+ employer paid?YESNOMore than 25% turnover of all drivers since last year?YESNOIsMore than 50% turnover of all drivers since last year?YESNODetails / Descriptions / NotesPhysical Address of Each TerminalAddressCityStateZip# Trucks GaragedGeneral InformationNumber of Years in BusinessNumber of Years with Workers Compensation InsuranceIf Buying Workers Compensation Insurance for the First Time; Why?Does applicant own/operate any other businesses?YESNODo drivers pull any double or triple trailers?YESNOCan drivers be dispatched from their home residence?YESNODescribe All “Yes” Answers from AboveMiscellaneous Information (Section Does Not Need to Total to 100%)AnswerQuestionPercent of Loads Hauled by Driving TeamsPercent of Trips that are Regular RoutesPercent of Trips that Involve Overnight TravelPercent of Miles Driven Between 10 PM and 6 AMPercent of Less-than-Truckload (LTL) HaulsRevenue by Driver Type (Must Total to 100%) [Explain Other* Answers in Blank Section at Bottom]Employee of ANY Named Insured (Full Time, Part Time, Seasonal, Etc.)Subcontractor of ANY Named Insured that DOES NOT have Workers Compensation InsuranceSubcontractor of ANY Named Insured that DOES have Workers Compensation InsuranceOtherDescribe All Other* Answers from AboveDriver Counts (Head-Count) [Only Drivers, Not Other Employees]Employee# FT# PTPer DiemAvg. WagePaid ViaHourlySalaryMileOwner Operator (No W/C Ins)# FT# PTPer DiemAvg. WagePaid ViaHourlySalaryMileFleet Operator (No W/C Ins)# FT# PTPer DiemAvg. WagePaid ViaHourlySalaryMileSubcontractor (No W/C Ins)# FT# PTPer DiemAvg. WagePaid ViaHourlySalaryMileSubcontractor (With W/C Ins)# FT# PTPer DiemAvg. WagePaid ViaHourlySalaryMileOther# FT# PTPer DiemAvg. WagePaid ViaHourlySalaryMileDescribe All Other* Answers from AboveFleet operators are drivers of trucks owned by an owner operator, but are not owner operators themselves.Other Employee Counts [Not Drivers] (No Need to List Other Clerical/Sales Employees)Mechanics / Yard Employees# FT# PT# OtherAvg. WagePaid ViaHourlySalaryDispatcher# FT# PT# OtherAvg. WagePaid ViaHourlySalaryOther# FT# PT# OtherAvg. WagePaid ViaHourlySalaryDescribe All Other* Answers from AboveFreight Interaction (Must Total to 100%) [Explain Other* Answers in Blank Section at Bottom]Drivers Load/Unload by HandDrivers Load/Unload with Manual Pallet JacksDrivers Load/Unload with Electric Pallet Jacks / ForkliftsDrivers Tailgate FreightDrivers Load/Unload Tanker Trailers (via Loading Rack)Drivers Load/Unload Tanker Trailers (via Trailer Ladder)Drivers Tarp Loads Manually (without Mechanical Tarping System)Drivers Tarp Loads Automatically (with Automatic Tarping System)Drivers Strap/Chain Loads on Flatbed / Drop-Deck / Step-Deck TrailersDrivers Perform Decking / Blanket-Wrapping / Etc.OtherDescribe All Other* Answers from AboveMaintenance Exposures (Check All That Apply)No Employee Mechanics (All Truck/Trailer Service/Repair Subcontracted to Others)YESNOOne or More Employees Perform Preventative Maintenance (e.g., brakes, oil, grease, etc.) ONLYYESNOOne or More Employees Mount and/or Repair/Retread TiresYESNOOne or More Employees Perform MOST non-warrantee service/repair workYESNOOne or More Employees Perform Work on a For-Hire Basis for Non-Owned EquipmentYESNOOne or More Employees Perform ANY tank entryYESNOOtherYESNODescribe All Other* Answers from AboveHaul Information (Each Section Must Total to 100%) [Explain Other* Answers in Blank Section at Bottom]Top Commodities Hauled (Describe Top 7 with % of Totals)Percentage of Radius of Ops (in Miles)Describe All Other* Answers from AboveEquipment Information (Each Section Must Total to 100%) [Explain Other* Answers in Blank Section at Bottom]Number of Tractors (Owned/Leased)Number of Trailers (Owned/Leased)Tractor TypeTrailer Type (Common)Trailer Type (Other)CaboverDry Box / VanAuto-TransporterConcrete MixerDrop-Deck/Step-DeckCompressed GasConventionalDump / Pneumatic DumpCurtain-SideDump TruckFlatbedDry BulkGarbage TruckIntermodal ContainerHopper BottomStraight/Box TruckLiquid TankerLivestockWreckerReeferLogging TrailerOtherOpen-Top Van (Chip)Walking FloorDescribe All Other* Answers from AboveOtherHazardous Materials Hauling1 - ExplosiveChemical Type% of HaulsPersonal Protective Equipment2 - GasesChemical Type% of HaulsPersonal Protective Equipment3 - Flammable / Combustible LiquidChemical Type% of HaulsPersonal Protective Equipment4 - Flammable / Combustible SolidChemical Type% of HaulsPersonal Protective Equipment5 - Oxidizing Substances / Organic PeroxidesChemical Type% of HaulsPersonal Protective Equipment6 - Poisons / Toxins / Infectious SubstancesChemical Type% of HaulsPersonal Protective Equipment7 - RadioactiveChemical Type% of HaulsPersonal Protective Equipment8 - CorrosiveChemical Type% of HaulsPersonal Protective EquipmentDescribe All Answers from AboveSubmit
