Occupational Accident Enrollment

• 1. The Occupational Accident coverage provided is not a contract for Statutory Workers' Compensation Insurance and neither the carrier above nor I become participants in the Workers' Compensation system by purchasing this insurance.
• 2. I certify to the best of my knowledge and belief that all information on this form is complete and truthful.
• 3. I am 18 years of age or older and I am under dispatch as a truck driver.
• 4. I am an independent contractor and receive a 1099 tax form, not a W-2 tax form for an employee, or I am an employee, but I am exempt from Workers’ Compensation insurance.

I understand that the cost of the insurance is my sole obligation and responsibility. I agree that I will forward any amount due to OOIDA upon demand, for any insurance at any time my account remains unpaid.

PARTICIPATION IN TRUST
I understand and acknowledge that by enrolling for insurance coverage I will become a Participant in the Owner Operator Independent Drivers Association, Inc. Insurance Trust and that I must abide by the terms and conditions of the Trust.

A copy of the Trust Agreement will be provided at the Enrollee's request. Please write to: OOIDA, 1 NW OOIDA Drive, Grain Valley, Missouri 64029.

FRAUD STATEMENT
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an enrollment form for insurance is guilty of a crime and may be subject to fines and confinement in prison.

IF THE INFORMATION YOU HAVE PROVIDED IS FRAUDULENT, WE MAY HAVE THE RIGHT TO RETURN PREMIUM AND CANCEL COVERAGE.

In the event of a claim, I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or any other organization, institution or person that has any records, including any medical records to furnish such information or copies of records to Atlantic Specialty Insurance Company, or OOIDA or its designated representative. A photographic copy of this authorization shall be as valid as the original.

In order to verify the information you have provided, you are giving us authority to examine the records that are maintained by the motor carrier and the Owner-Operator Independent Drivers Association.