CAPS Program Questionnaire
Please answer ALL questions, unless inapplicable.

Named Insured: 

Are you also interested in Workers Compensation protection for your employees
(with no charge or audit risk for IC's)?    Yes     No

Phone:        Fax:  

Type of Organization:
Select One Corporation LLC Partnership Sole Proprietorship

Federal Employer ID Number:

Contact Person:  
Title:  

E-mail:  

Year Established:     (If less than 3 years, describe experience)

Owners / Exec. Officers: (names, titles, % ownership)

Number of Locations:

States Where You Have Offices: 

Complete Addresses of all Locations: (if more than one, indicate HQ)

Operations Information:

Current Number of Indep. Contractor Drivers based in Each State:
    State 1:                      No. I/Cs: 
    State 2:                      No. I/Cs: 
    State 3:                      No. I/Cs: 
    State 4:                      No. I/Cs: 
    State 5:                      No. I/Cs: 

Do You handle, under your operating authority, any HAZMAT?
   Yes     No        If Yes, explain:

Radius of Operations:  % of Trips 0-50 Miles:     % Over 50 mi. 

Parcel Weight:  0-50 lbs: %    50-100 lbs: %    over 100 lbs: %

Describe handling if other than manual:

Is Casual Labor used?     Yes     No    If Yes, explain:

Are Bikes or Mopeds used?     Yes     No        If Yes, how many?

Are Foot Messengers used?    Yes     No       If Yes, how many?

Do you operate a Warehouse?    Yes     No   Describe:

 
Plan Information/History:

Do you currently sponsor an Occupational Accident and/or Workers Comp. plan for contract drivers?   Yes     No 

If yes, provide the information in the table below for the past 3 years as well as copies
of policies or certificates, loss runs, and explanation of claims over $50,000.

Will you settle/deduct premiums on behalf of the Contract Driver for this Plan?   Yes     No

Will the Occupational Accident Plan (CAPS) be mandatory for all Contract Drivers?   Yes     No

How will plan information / coverage be communicated to drivers?

Do you utilize an outside vendor for IC "payroll" services?   Yes     No
   If yes, you agree to provide CAPS program Administrators with information necessary
    and relevant to the adjudication of claims made by insured contractors.

Safety, Losses, and Loss Prevention:

W.C. Experience Modification Factor:      (check here if none: )

In the past 3 years, have you defended against an independent contractor claiming employee status?    Yes     No.    How many W.C. Awards?    Details:

Person Responsible for Safety:     Title:
    Years with You:         Years of Loss Prevention work:

Provide Minimum Standards for Contractor Drivers:
    Min. Age:             Max. Age:                   
    Do you run MVR's?     Yes     No 
    Max. number of Accidents permitted in 3 years:  
    Max. number of Moving Violations permitted in 3 years:  

Describe any other hiring standards, guidelines, and procedures for IC's
     -- such as orientation, vehicle standards, experience, etc.
   

Do you provide training or ongoing safety meetings for IC?    Yes     No. 
    Describe all safety programs, training, meetings, incentives: 
    Attach copies of any written materials
   

Do you utilize a standard "lease" or "contractor" agreement for all IC drivers?
    Yes     No      If yes, remember to fax a copy to KBS (914-636-0802)

Does the lease agreement, contract, or written procedures require the following of the IC?
    a.  Yes  No   He owns his equipment or holds it under a bonafide lease arrangement.  
    b.  Yes  No   He is responsible for the maintenance of the vehicle.   
    c.  Yes  No   He bears the principal burdens of the vehicle operating costs.   
    d.  Yes  No   He is responsible for hiring and supervising necessary personnel.   
    e.  Yes  No   His compensation is based on factors related to the work, not time.   
    f.   Yes  No   He is responsible for selecting the method/ means of performing svcs.   
    g.  Yes  No   He has entered into an indiv. written contract that specifies his 
                                  relationship to be that of an independent contractor, not an employee. 

Notes / Comments:

By submitting this form you agree that to the best of your knowledge, the information given is accurate and factual, understanding that this form does not bind any Agent, Carrier, or Administrator to coverage.  This is a Quotation Request Form and will not effect any insurance until approved in writing from carrier's authorized representative.

Thank you for turning to KBS.  Be sure to provide the documents we
requested at the top of this page if possible.  We will get back to you soon!

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