Truckers Supplemental Application {SI-7}

WORKER'S COMPENSATION BOARD OF INDIANA 402 WEST WASHINGTON STREET, ROOM W196 INDIANAPOLIS, IN 46204-2753 www.in.gov/workcomp TRUCKERS SUPPLEMENTAL APPLICATION FORM SI-7 (Revised 2003) 1. Do you or your employees operate out of a base terminal? ___YES__ NO A. If YES, please give terminal address(es): _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ A list of drivers and their addresses assigned to each terminal must be attached. B. If NO, do you or your employees spend a majority of driving time in any one state? _____YES - Give state of majority driving time for yourself and/or each employee: _______________________________________________________________________ _______________________________________________________________________ _____NO - Give your and/or your employees' state(s) of residence: _______________________________________________________________________ _______________________________________________________________________ 2. Do you lease employees to other firms? ___YES ____NO A. If YES, list firm name(s) and street address(es)of locations where leased employees are operating: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ http://www.in.gov/workcomp/forms/Self-Ins/2003TruckersSupplementalApplication.doc American LegalNet, Inc. www.FormsWorkflow.com AGREEMENT OF APPLICANT The undersigned employer hereby certifies that the statements in this application have been read and understood. Furthermore, in consideration of the issuance of the approval to self-insure in the State of Indiana, the undersigned also certifies under the penalties of perjury, that the statements in this application are true and agrees: A.____ To maintain a complete record of all payroll transactions in such a manner as the Worker's Compensation Board may reasonably require, and such record will be available to the Board at the designated address. B. The applicant certifies that only those truckers/employees shall be assigned to this state in which the base terminal from which they truck on a regular basis is located. For purposes of these procedures, the following definitions shall apply: BASE TERMINAL: A permanent location with central loading docks and/or storage facilities where a trucker regularly goes to load, unload, store or transfer freight. STATE OF RESIDENCE: The state in which the trucker resides as evidenced by the location used for the filing of federal income taxes. REGULAR: A pattern of 40 hours per week or any other pattern that appears on a continuing basis. STATE OF MAJORITY DRIVING TIME: State where trucker spends more time driving in or through than any others. Must be verifiable. C.____ To comply substantially with all laws, orders, rules, guidelines, and regulations in force and effect made by the public authorities and with all reasonable recommendations made by the Worker's Compensation Board, relative to the welfare, health and safety of the employees. _________________________ BUSINESS NAME OF EMPLOYER _________________________ DATE OF APPLICATION ____________________________ SIGNATURE OF COMPANY OFFICER ____________________________ TITLE OF COMPANY OFFICER http://www.in.gov/workcomp/forms/Self-Ins/2003TruckersSupplementalApplication.doc American LegalNet, Inc. www.FormsWorkflow.com