Independent contractors truck insurance application

Submit our online Independent Contractors Application or click to download a printable PDF format version of the Independent Contractors Application.

Yes

ADD

DELETE

CHANGE

Dedicated Reimbursement

Today's Date

Downtime

Non-Trucking Use

Effective Date

Misc. Equipment

Occupational Accident


	ADD:	Unit #	Sym	Year	Make	Serial #	Value
1.
	Loss Payable
2.
	Loss Payable
3.
	Loss Payable:

	DELETE:	Unit #	Sym	Year	Make	Serial #
1.
2.
3.

Occupational Accident Enrollment:
Unit #	SS#
Date of Birth
Hire Date	Termination Date

For my convenience, I request the above motor carrier to deduct monthly from settlements due me, any premiums I may owe to the Great West Casualty Company and remit that amount to the insurance company and its authorized representative.
Name of Owner/Operator Address
City	State	Zip
Email
Phone

Submit our online Independent Contractors Application or click to download a printable PDF format version of the Independent Contractors Application.