Blanket enrollment form


Applicant’s Signature_________________________________________________ Date



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Jean Christnor Romelus Insurance Logix

Applicant’s Signature_________________________________________________ Date
________________________________ 
Lovely Joseph
2613 Cashwell Dr Goldsboro NC 27534
Best Friend
791-09-4464
11/01/2021
DocuSign Envelope ID: 5DB66D44-F263-4802-B38C-DAD3A5D225D8


WORKERS' COMPENSATION INSURANCE REJECTION 
ACKNOWLEDGEMENT FORM
I am an Independent Contractor/Owner Operator contracting with: 
________________________________
I have been given the choice by the Motor Carrier listed above to either provide 
them with proof that I have purchased either Workers' Compensation 
insurance for myself which names them as an Alternate Employer, or provide 
proof that I have Occupational Accident insurance coverage that is acceptable 
to the motor carrier.
I understand that Occupational Accident insurance is not Workers' 
Compensation insurance and that it provides less benefits than Workers' 
Compensation. I also understand that Occupational Accident insurance costs 
less than Workers' Compensation.
It is my right as an Independent Contractor and as a sole proprietor or 
executive officer of my Company, to exercise my option not buy Workers 
Compensation insurance on myself. I am choosing not to purchase Workers' 
Compensation. Instead I am choosing to buy Occupational Accident 
insurance instead of Workers' Compensation even though the coverage is 
different.
I VERIFY THAT I HAVE READ THIS AGREEMENT AND THAT I AM 
CHOOSING TO BUY OCCUPATIONAL ACCIDENT INSURANCE AND NOT 
WORKERS' COMPENSATION INSURANCE:
Print Name: _________________________________ 
Contractor Signature: _______________________________ 
Date: _________________ 
USA Trucking Association 
Occupational Accident Insurance Program
KBB Logix Inc.
Jean Christnor Romelus
11/01/2021
DocuSign Envelope ID: 5DB66D44-F263-4802-B38C-DAD3A5D225D8

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