Other States Coverage ­ Trucking Supplemental Application All applicants for BWC's Other States Coverage with trucking classifications must complete this supplemental application, in addition to the ACORD 130, as part of the underwriting process. You can acquire the ACORD 130 by contacting the Other States Coverage Unit by emailing BWCotherstatescoverage@bwc.state.oh.us, by calling 614-728-2053 or by contacting your insurance agent. BWC will not provide quotes for coverage without a completed supplemental application. Business name U.S. Department of Transportation number Form completed by (name) BWC policy number Public Utilities Commission of Ohio number Contact phone number Contact email address 1. Please describe the nature of your trucking operation. 2. List each state in which known travel occurs. Please note: "all states" is not a satisfactory answer. We need to know what individual states the policy should include. In addition, some states require an employer to register and obtain an unemployment identification number. You must do this before we can issue a policy. 3. Is the average distance an employee drives 250 miles or less? 4. Please list all commodities hauled. Yes No A. Are any commodities hazardous, explosive or contain asbestos? B. If yes, please list specific commodities. Yes No BWC-7665 (Rev. July 14, 2016) U-159 American LegalNet, Inc. www.FormsWorkFlow.com Other States Coverage ­ Trucking Supplemental Application 5. Do you or your employees operate out of a home terminal? Yes No Home terminal refers to the place of business of a motor carrier at which a driver ordinarily reports for work. This is the business location where drivers pickup trucks. A. If yes, provide the address(es) for each home terminal. B. If terminals are located outside of Ohio, provide an estimation of payroll for employees reporting to each terminal. C. If no, where do you garage the motor carriers? 6. Please list all states of residence for employees. State of residence is the state used by the driver/trucker for filing federal income taxes. A. If employees' residences are located outside of Ohio, provide an estimation of payroll for each state where employees live. 7. Does your company use owner-operators? A. If yes, how many? Yes No B. Please list states of residence for owner-operators. BWC-7665 (Rev. July 14, 2016) U-159 American LegalNet, Inc. www.FormsWorkFlow.com Other States Coverage ­ Trucking Supplemental Application C. If yes, submit evidence of coverage in the form of a certificate or exemption for each owner-operator. D. If yes, please list specific commodities. E. Are the tractors titled in the name of the owner-operator? 8. Do you issue IRS Form 1099 to any of your drivers? 9. Are all of your drivers classified as company drivers? Yes Yes Yes No No No 10. State unemployment tax ID numbers are needed for the states of HI, NJ, NY, ME, MN, RI, and UT. If you are requesting coverage in any of these states, please list the applicable number or numbers below. If you do not have a state unemployment tax ID number, you will need to request one from the applicable state. The number must be supplied to the OSC underwriter prior to policy issuance. _______________________________________________________________________________________________ By my signature, I certify I have the authority to execute this application, and that the facts set forth on this application are true and correct to the best of my knowledge and belief. I am aware that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Applicant's name (please print) Date Producer's name (please print) Date By my signature, I certify I have the authority to execute this application, and that the facts set forth on this application are true and correct to the best of my knowledge and belief. Applicant's signature Date Producer's signature Date BWC-7665 (Rev. July 14, 2016) U-159 American LegalNet, Inc. www.FormsWorkFlow.com