Blanket enrollment form



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Jean Christnor Romelus Insurance Logix



B-OCCACC-TA-ENROLL (6/13)
Pan-American Life Insurance Company 
New Orleans, Louisiana 
BLANKET ENROLLMENT FORM
Sponsoring Association: USA Trucking Association
Participant Sponsor: ______________________________________________________________________________
_____________________________________________ 
___________________________________ 
Applicant Name
Gender
Street Address
 
___________________________________ _______ ___________ ________________ _____________
__
______ 
City State Zip DOB
SSN
 
___________________________ ____________________________ __________________________ 
Home Phone
Business Phone
Start Date 
LEGAL STATUS (Please Check One): 
Sole Proprietor Partnership
Corporation
LLC
Other: ________________________________
DO YOU HAVE ANY W-2 EMPLOYEES: YES: 
NO: 
IF YES, HOW MANY?: 
_____________
 
APPLICANT: 
(Check Only One) 
Class 1 - Owner/Operator
Class 2 – Scheduled Co-Driver 
Class 3 – Scheduled Contract Driver of Owner/
Operator
Class 4 – Independent Contractor (not otherwise classified)
 
Class 5 – Scheduled Laborer 
Description of Class 1, 2, 3, 4 & 5:
Class 1
– “Owner Operator” means a person who meets all of the following definitions: 

is an Independent Contractor as defined by the law;

owns or leases the motor vehicle;

has the responsibility for determining the time, means and method of performing the work;

has entered into a covered contract with the Participant Sponsor;

is compensated on a Form 1099 and not a Form W-2; and

does not own or control the Participating Sponsor.
Class 2
– “Co-Driver” means a person who meets all of the definitions in Class 1 and: 

co-owns or co-leases a motor vehicle which is under a long term lease contract with the Participant Sponsor; and

drives the motor vehicle as an Independent Contractor, as defined by the law.
Class 3
– “Scheduled Contract Driver of Owner/Operator” means a person who meets all of the following definitions: 

drives a motor vehicle owned or leased by an Owner Operator;

is an Independent Contractor as defined by the law;

works under a covered contract that provides for possible financial loss or gain by the Contract Driver relative to the
operation of the motor vehicle being utilized;

has the responsibility for determining the time, means and method of performing the work; and

is compensated on a Form 1099 and not a Form W-2.
Class 4
– “Independent Contractor (not otherwise classified)” means a person who meets all of the following definitions: 

drives a motor vehicle owned by the Participant Sponsor,

works under a Covered Contract
 
that provides for possible financial loss or gain by the Independent Contractor (not
otherwise classified) relative to the operation of the motor vehicle being utilized;

has the responsibility for determining the time, means and method of performing the work; and

is compensated on a Form 1099 and not a Form W-2.
Class 5
– “Casual Laborer” means a temporary helper or laborer who is picked up at or near a pre-determined delivery 
address; is not an employee of the Dispatcher, the moving and storage company, the home delivery company, the 
covered Subscriber or the Participant/Sponsor; is used only to unload the contents of the delivery vehicle at a 
pre-determined delivery address. 
KBB Logix Inc.
Jean Christnor Romelus
male
1005 Cannock DR
Kissimme
FL
34758
12/04/1985
073-71-4091
224-223-5664
04/26/2021



DocuSign Envelope ID: 5DB66D44-F263-4802-B38C-DAD3A5D225D8


B-OCCACC-TA-ENROLL (6/13) 

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