Hudson OCAC Enrollment

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Driver Enrollment Date:

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

First Last

Date of Birth

Address

Street Address Address Line 2 City (CDL#/State) ZIP / Postal Code Country

CDL#/State

Beneficiary Name

Relationship

Contact Info

By signing this Membership Election and Request for Insurance the Independent Contractor agrees to all of the following:

First Check Mark

I certify that I am an Owner Operator paid on a 1099 performing contracted services pursuant to written agreement, in a position to incur profit or loss, and determine the method, manner and means to perform my work assignment.

I certify that I am Contract Driver paid on a 1099 performing contracted services pursuant to written agreement, in a position to incur profit or loss, and determine the method, manner and means to perform my work assignment.

Third Check Mark

I am applying for membership in the Avantage Association, LLC, a Georgia Limited Liability company. I understand that enrollment in the association is required to be eligible for coverage, and I have been provided the "Avantage Association Membership Terms and Conditions Form."

Forth Check Mark

I shall make such premium and membership dues payments as may be required for the program being provided.

Fifth Check Mark

That all of the statements made in this Request are, to the best of my knowledge and belief, true and accurate.

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

(Signature of Covered Driver)

Date

I have read and agree to the Terms and Conditions of AVANTAGE Membership as stated hereon.

Name of Applicant (Please Print):

First Last

Applicant's Signature

Date Signed

Owner Operator Driver Onboarding

Hudson OCAC Enrollment

Participating Motor Carrier: Tralo Companies, Inc.