Step 1 of 3 33% Name* First Last Home Phone*Cell PhoneEmail* SS or FEIN #*CDL #*Street Address*Address Line 2City*State*AlabamaArkansasArizonaCaliforniaFloridaGeorgiaIowaIllinoisKentuckyMichiganMissouriMississippiNorth CarolinaNorth DakotaNew JerseyNevadaOhioOklahomaOregonPennsylvaniaSouth CarolinaTennesseeTexasUtahVirginiaWashingtonHeight*Weight*Gender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Beneficiary*Relationship to Beneficiary* General InformationYOU ARE NOT ELIGIBLE FOR COVERAGE IF YOU ARE AN EMPLOYEE DRIVERYou are are paid by*W-21099Do you own and operate your own truck?*YesNoDo you operate a truck under a lease to purchase plan?*YesNoDo you operate a truck as a 1099 contract driver, but do not own or lease the truck?*YesNoIf Yes, with whom?Do you operate a truck as part of a team or as a co-driver?*YesNoIf Yes, with whom?Equipment Type* Box Flatbed Intermodal Tanker Refrigerated Dump Straight Truck Other If Other, please specifySigned Copy of Independent Contractors Lease Agreement*Accepted file types: jpg, png, pdf.Maximum Upload Size is 6MB. To attach the file, click "browse" or "choose" and navigate to the folder where you saved the image or document. Select the image or document(s) and click "Open" or "Select."Have you filed a workers' compensation or occupational accident claim in the past 3 years?*YesNoIf Yes, please explainHave you filed for bankruptcy in the last 5 years?*YesNoAre you covered under any other medical and/or disability insurance plan?*YesNoIf Yes, Name of Insurance CarrierPhoto of Front and Rear of Driver's License* Drop files here or Accepted file types: jpg, png, pdf. To attach the file, click "Select files" and navigate to the folder where you saved the image or document. Select the image or document(s) and click "Open" or "Select." TERMS AND CONDITIONSRead the terms & conditions*INSURANCE FRAUD WARNING Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. The undersigned individual(s) certifies the following: (1) the information provided in connection with this application is true and accurate and has been submitted to obtain commercial insurance; (2) Engs Insurance Agency LLC ("EIA") and Engs Commercial Finance Co. ("ECF") is authorized to investigate and verify any information provided and to make inquiry of references, other creditors or lessors as to credit worthiness; (3) applicant(s), driver(s), guarantor(s), owners, principals named above, (hereafter referred to as "Customer") and/or any individual whose name appears on the application explicitly authorizes any consumer reporting agency, motor vehicle reporting service and other individuals to provide credit or driving information to EIA and its subsidiaries and affiliates or any of its insurance agents or carriers for use in connection with underwriting or issuing insurance. EIA, its subsidiaries and affiliates, its insuring partners and joint users of such information are authorized to receive, exchange and to update such credit or driving information as appropriate during the term of the transaction. EIA will require proof of identity as required under the USA Patriot Act. I hereby consent to receive telephone, cell phone, e-mail or faxed communications from EIA. You hereby authorize us to share your information for marketing purposes. You must provide us written notification that you do not want us to share your information (except transactional or experience information). Please direct your request to ECF ATTN: Chief Risk Officer, at credit@engsfinance.com. Please include a copy of your driver’s license. I hereby request enrollment for the Occupational Accident policy set forth above. I understand and acknowledge that I am an Independent Contractor and receive a 1099 tax form, and that as such, the cost of this insurance is my sole obligation and responsibility. In enrolling for this insurance coverage I hereby acknowledge and agree that I meet the eligibility requirements of this policy, and that I am not an employee of any company for which I perform services. I further understand and acknowledge that this is NOT WORKERS COMPENSATION INSURANCE. I CERTIFY TO THE BEST OF MY KNOWLEDGE and belief that all information on this form is complete and truthful. By selecting the checkbox below, you are confirming that you have read the terms and conditions outlined above. I have read and agree to the terms and conditions above Electronic Signature Agreement*By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You further agree that your use of a key pad, mouse or other device to type your name constitutes your signature as if actually signed by you in writing. I Accept APPLICANT CONSENT: By submitting this application, the submitting individual(s)certifies the following: (1) the information provided in connection with this application is true and accurate and has been submitted to obtain commercial credit; (2) Dealer , Engs Commercial Finance Co. (“ECF”), and any affiliates of ECF, jointly or separately, are authorized to investigate and verify any information provided and to make inquiry of references, other creditors or lessors as to credit worthiness; (3) applicant(s), guarantor(s), owners, principals, named above, and/or any individual whose name appears on the application explicitly authorizes any consumer reporting agency and other individuals to provide credit information to Dealer, ECF and any affiliate of ECF for use in connection with the transaction; and (4) the individual submitting this application is duly authorized to execute and submit this application. The applicant expressly authorizes any references listed in the application to release requested credit, financial and business information for use in connection with the transaction. Dealer, ECF, any affiliates of ECF and joint users of such information are authorized to receive, exchange and to update such credit information for so long as needed for these purposes. ECF or its affiliates may contact the applicant and transmit information electronically (including email, text and instant messages) at any email address or telephone number (including a wireless telephone number) provided.
