Insurance Survey

Company Name

DOT or MC #:

# of Employee Drivers:

# of Power Units:

# of Owner/Operators:

# of Owner/Operator Power Units:

Workers Compensation HighMediumLow

Occupational Accident HighMediumLow

Automobile Liability HighMediumLow

Automobile Physical Damage HighMediumLow

Workers Compensation

Occupational Accident

Automobile Liability

Automobile Physical Damage

Claims Support HighMediumLow

Risk Control Services HighMediumLow

Certificates of Insurance HighMediumLow

Owner/Operator and Employee Relationship Audits HighMediumLow