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NEW JERSEY WORKERS COMPENSATION INSURANCE PLAN TRUCKERS SUPPLEMENTAL APPLICATION - page 1 / 1

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NEW JERSEY WORKERS COMPENSATION INSURANCE PLAN TRUCKERS SUPPLEMENTAL APPLICATION

DATE (MM/DD/YYYY)

1.

NAME

(Submit in duplicate) If space restricts a complete answer, attach answer on separate sheets of paper, in duplicate. 3. HOME PHONE

2.

BUSINESS ADDRESS

BUSINESS PHONE

4.

FEIN

NJTIN

5. If you or your employees operate out of a base terminal, give terminal address(es): You must attach a list of drivers assigned to each terminal.

6. If you or your employees spend a majority of driving time in a certain state, name that State for yourself and each employee:

7. If you do not drive a majority of time in any one state, give yours and your employees’ state(s) of residence:

8. Do you, or companies with whom you have contracts, use any owner-operators? If yes, list them below:

Yes

No

NAME - ALL DRIVERS

HOME ADDRESS

Yes

No

Yes

No

9. Do you have workers compensation certificates of insurance on file for each owner-operator? If yes, attach copies of same. If no, is payroll included on application for coverage?

10. Do you lease employees to other firms?

Yes

No

If yes, list firm name(s) and street address(es) of locations

where leased employees operate: Include Supplemental Employee Leasing Application.

11. With whom is your largest hauling contract?

FIRM

ADDRESS

12.

Agreement of Applicant

I certify I read and understand the statements in this application. Also, I certify the statements in this application are true and agree to the following conditions:

  • A.

    To maintain a complete payroll transaction record as the insurance company may require, and to have these records available to the company and Rating Bureau at the business address.

  • B.

    To obey all laws, orders, and rules of the public authorities and with recommendations made by the insurance company about the welfare, health and safety of the employees.

Business Name of Employer

Signature

Date of Application

Title

  • *

    Definitions

Base Terminal: A permanent location with central loading docks or storage facilities where a trucker regularly loads, unloads, stores or transfers freight. State of Residence: The state where the trucker lives and files Federal Income Tax returns.

ACORD 136 NJ (2006/01)

© ACORD CORPORATION 1996-2006

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