- OOIDA

Plan Enrollment

Please indicate which plan you are enrolling in*

Casual Laborer coverage is available with the $1 Million Plan and the $2 Million Plan.

Would you like to add Casual Laborer coverage?*

No
Yes

GENERAL INFORMATION

Are you an Owner/Operator with your own authority?*

Yes
No

Are you an Owner/Operator leased to a company?*

Yes
No

Are you a:*

*Co-Driver
Contract Driver (and receive a 1099 form)
Employee (and receive a W-2 form)

*If you select Co-Driver, you will need to add a Co-Driver form in the next step.

I hereby confirm that I am a Full-Time Co-Driver with the Primary Driver that I have listed below, and that I drive in the same unit with this person at all times. If at any time I become the sole driver for more than fourteen (14) days, I will immediately notify OOIDA. I further understand that if this occurs, I will become a Primary Driver and my rate will be adjusted accordingly. I also understand that if I give any inaccurate, false or misleading information to OOIDA, any benefits for which I am eligible under this insurance coverage will be denied.

Co-Driver Form

Primary Driver Name	Primary Member#	Co-Driver Name	Co-Driver Member#	Signature	Actions

There are no Entries.

What do you haul?*

PERSONAL INFORMATION

Member Number

First Name*

Last Name*

Address*

Social Security Number*

Date of Birth*

Home Telephone Number

Cell Phone Number

Email Address*

CDL Number*

BENEFICIARY INFORMATION

Beneficiary Name*

Relationship to Insured*

Address of Beneficiary*

AUTHORIZATION

I hereby authorize OOIDA to bill the following selected party for my future Occupational Accident coverage payments:

Self
Motor Carrier, as listed on the front of this Form
Other

Other

Name*

Address*

Phone*

Email*

AH 282 OA OOIDA 06 07 (8-14 Rev)

I understand and hereby state:

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, you 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.

YOU MUST SELECT THE CHECKBOXES BELOW AND SIGN:*

I UNDERSTAND AND AGREE

Occupational Accident Enrollment

Plan Enrollment

GENERAL INFORMATION

PERSONAL INFORMATION

BENEFICIARY INFORMATION

COMPANY INFORMATION

AUTHORIZATION

Other

Primary Driver

Co-Driver