Hudson OCAC Enrollment

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Under Policy Number HOA101-00363, issued through the Advantage Association under the Hudson Insurance Company Group and Blanket Accident & Health Insurance Trust.

Participating Motor Carrier: Tralo Companies, Inc.

Covered Driver Name
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By signing this Membership Election and Request for Insurance the Independent Contractor agrees to all of the following:
First Check Mark
Third Check Mark
Forth Check Mark
Fifth Check Mark
AMOUNTS OF INSURANCE requested are listed on the Benefit Summary Schedule provided upon enrollment in the program. A full copy of the Occupational Accident policy is available upon request.
EFFECTIVE DATE OF INSURANCE- is the date on file with the administrator of this program provided this request has been approved by Hudson Insurance Company and its Underwriting Manager, and the proper premium has been paid.
I hereby request enrollment as a Member in the Avantage Association and hereby elect to participate in the Occupational Accident program set forth above. I declare and acknowledge that I am an INDEPENDENT CONTRACTOR, and that as such, the cost of this program and insurance are my sole obligation and responsibility. By enrolling for this insurance coverage, I hereby acknowledge and agree that I meet the eligibility requirement of this coverage, 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.
(Signature of Covered Driver)
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I have read and agree to the Terms and Conditions of AVANTAGE Membership as stated hereon.
Name of Applicant (Please Print):
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