ACORD 136NJ Instructions


ACORD 136 NJ (2009/09) rev. 08-31-2009 1 of 4
Section Name Field Name Field and/or Section Description
TITLE ACORD 136 NJ (2009/09) New Jersey Workers CompensationInsurance PlanTruckers Supplemental Application The title of the form. ACORD 136 NJ, New Jersey Workers Compensation Insurance Plan Truckers SupplementalApplication, is used as a supplement to ACORD 133 NJ, when applying to the Compensation Rating and Inspection Bureau of New Jersey for Workers Compensation insurance for truckers. Contact the Compensation Rating and Inspection Bureau for instructions on thecompletion of this form.
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Name Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Business Address Enter text: The named insured’s physical address line one.
IDENTIFICATION SECTION Enter text: The named insured’s physical address line two.
IDENTIFICATION SECTION Enter text: The named insured’s physical address city name.
IDENTIFICATION SECTION Enter code: The named insured’s physical address state or province code.
IDENTIFICATION SECTION Enter code: The named insured’s physical address postal code.
IDENTIFICATION SECTION Home Phone Enter number: The named insured’s primary phone number. As used here, this is the home phone number.
IDENTIFICATION SECTION Business Phone Enter number: The named insured’s secondary phone number. As used here, this is the business phone number.
IDENTIFICATION SECTION FEIN Enter identifier: The tax identifier of the named insured. As used here, this is the federal employer identification number.
IDENTIFICATION SECTION NJTIN Enter identifier: The tax identifier of the named insured. As used here, this is the New Jersey tax identification number.
TERMINALS Terminal Address One Enter text: The first address line of the physical location. As used here, this is a terminal address.
TERMINALS Enter text: The city of the physical location.
TERMINALS Enter code: The state or province of the physical location.
TERMINALS Enter code: The postal code of the physical location.
TERMINALS Terminal Address Two Enter text: The first address line of the physical location. As used here, this is a terminal address.
TERMINALS Enter text: The city of the physical location.
ACORD 136 NJ (2009/09) rev. 08-31-2009 2 of 4
Section Name Field Name Field and/or Section Description
TERMINALS Enter code: The state or province of the physical location.
TERMINALS Enter code: The postal code of the physical location.
TERMINALS Terminal Address Three Enter text: The first address line of the physical location. As used here, this is a terminal address.
TERMINALS Enter text: The city of the physical location.
TERMINALS Enter code: The state or province of the physical location.
TERMINALS Enter code: The postal code of the physical location.
STATE OF OPERATION Majority State Enter text: The majority driving state for the named insured and each employee. As used here, this in entered if you or your employees spend a majority of driving time in a certain state.
STATE OF OPERATION Employees State of Residence Enter text: The state of residence for the named insured and each employee. As used here, this is entered if you do not drive a majority of time in any one state.
OWNER/OPERATOR INFORMATION Do you, or companies with whom you have contracts, use any owner-operators? Yes. Check the box (if applicable): Indicates a “Yes” response to the question, “Do you, or companies with whom you have contracts, use any owner-operators?”.
OWNER/OPERATOR INFORMATION Do you, or companies with whom you have contracts, use any owner-operators? No. Check the box (if applicable): Indicates a “No” response to the question, “Do you, or companies with whom you have contracts, use any owner-operators?”.
OWNER/OPERATOR INFORMATION Name all Drivers Enter text: The driver’s full name.
OWNER/OPERATOR INFORMATION Enter text: The driver’s full name.
OWNER/OPERATOR INFORMATION Enter text: The driver’s full name.
OWNER/OPERATOR INFORMATION Drivers Home Addresses Enter text: The first address line of the driver.
OWNER/OPERATOR INFORMATION Enter text: The city of the driver.
OWNER/OPERATOR INFORMATION Enter code: The state or province of the driver.
OWNER/OPERATOR INFORMATION Enter code: The postal code of the driver.
OWNER/OPERATOR INFORMATION Enter text: The first address line of the driver.
OWNER/OPERATOR INFORMATION Enter text: The city of the driver.
ACORD 136 NJ (2009/09) rev. 08-31-2009 3 of 4
Section Name Field Name Field and/or Section Description
OWNER/OPERATOR INFORMATION Enter code: The state or province of the driver.
OWNER/OPERATOR INFORMATION Enter code: The postal code of the driver.
OWNER/OPERATOR INFORMATION Enter text: The first address line of the driver.
OWNER/OPERATOR INFORMATION Enter text: The city of the driver.
OWNER/OPERATOR INFORMATION Enter code: The state or province of the driver.
OWNER/OPERATOR INFORMATION Enter code: The postal code of the driver.
OWNER/OPERATOR INFORMATION Do you haveworkers compensationcertificates of insurance on file for each owner-operator? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Do you have compensation certificates of insurance on file for each owner-operator?”.
OWNER/OPERATOR INFORMATION Do you have workers compensation certificates of insurance on file for each owner-operator? No Check the box (if applicable): Indicates a “No” response to the question, “Do you have compensation certificates of insurance on file for each owner-operator?”.
OWNER/OPERATOR INFORMATION If no, is payroll included on application for coverage? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Is payroll included on application for coverage?”.
OWNER/OPERATOR INFORMATION If no, is payroll included on application for coverage? No Check the box (if applicable): Indicates a “No” response to the question, “Is payroll included on application for coverage?”.
OWNER/OPERATOR INFORMATION Do you lease employees to other firms? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Do you lease employees to other firms?”.
OWNER/OPERATOR INFORMATION Do you lease employees to other firms? No Check the box (if applicable): Indicates a “No” response to the question, “Do you lease employees to other firms?”.
LEASING INFORMATION Firm names and addresses Enter text: The full name of the location.
LEASING INFORMATION Enter text: The first address line of the physical location.
LEASING INFORMATION Enter text: The city of the physical location.
LEASING INFORMATION Enter code: The state or province of the physical location.
LEASING INFORMATION Enter code: The postal code of the physical location.
LEASING INFORMATION Enter text: The full name of the location.
LEASING INFORMATION Enter text: The first address line of the physical location.
LEASING INFORMATION Enter text: The city of the physical location.
Section Name Field Name Field and/or Section Description
LEASING INFORMATION Enter code: The state or province of the physical location.
LEASING INFORMATION Enter code: The postal code of the physical location.
LEASING INFORMATION Firm Enter text: The full name of the organization. As used here, this is the name of the largest hauling contract.
LEASING INFORMATION Address Enter text: The first line of the organization’s mailing address. As used here, this is the address of the largest hauling contract.
LEASING INFORMATION Enter text: The city of the organization’s mailing address. As used here, this is the address of the largest hauling contract.
LEASING INFORMATION Enter code: The state or province of the organization’s mailing address. As used here, this is the address of the largest hauling contract.
LEASING INFORMATION Enter code: The postal code of the organization’s mailing address. As used here, this is the address of the largest hauling contract.
SIGNATURE Business Name of Employer Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SIGNATURE Signature Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE Date of Application Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
SIGNATURE Title Enter text: The title of the individual in the organization or his relationship to the organization.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).