Trucking Questionnaire

Less than 200 miles from point of principal garagingMore than 200 miles from point of principal garaging Please Print or Type Policyholder NameFor your protection, Utah law requires the following to appear on this form:Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in the state prison. Signature and Title of Owner, Partner, Member or Corporate OfficerDatePolicy Number 2 INFORMATION1 POLICY1 In what state do you regularly operate?6 Do you own / operate terminals? If yes, list locations.5 In which states do you have workers' compensation policies?3 Are all employees residents of Utah? If no, list all other states in which your employees reside.4 Are all employees hired in Utah? If no, list all other states in which your employees are hired.2 Is the radius of your operations more or less than 200 miles from point of principal garaging? Please return a completed signed application to:WCF InsuranceAttn. Underwriting Department100 West Towne RIdge ParkwaySandy, Utah 84070If you have any questions, please call 385.351.8015or 800.446.2667 ext.8015Fax: 385.351.8166 Trucking QuestionnaireWCF Mutual Insurance Company American LegalNet, Inc. www.FormsWorkFlow.com