FORM-TRS Occupational Accident Plan – TRS Insurance | Reliable. Comprehensive. Service Driven.

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TRS Occupational Accident Plan

Application for approval into the TRS Master Occupational Accident Plan for Owner Operators

Agency Name

Producer Name

Email *

Name of Enrollee

Complete Address of Enrollee

Number of Years Experience

Date of Birth

Gender

Indicate type of driver

Owner Operator
Co-Driver
Contract Driver
Scheduled Co-Driver
Fleet Driver
Team Driver

Is the certificate of title in your name?

Yes
No

Number of Accidents in last 36 Months?

Do you driver for another person?

Yes
No

Do you load or unload?

Yes
No

Do you use tarps or chains?

Yes
No

Do you attach or detach any trailers?

Yes
No

What type of transmission do you drive?

Automatic
Manual

Choose a radius

Over 100 miles per trip
Under 100 miles per trip

Do you haul or drive any of the following? (Check all the apply)

Flatbed
Livestock
Dump Trucks
Garbage / Refuse
Furniture Moving & Storage
Other
Intermodal
Tanker
Dump Trailers (Side or End Dump)
Chemicals
Vehicles with GVW <20,000 lbs

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