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

Yes
No
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.
cline wood