Owner Operator Application (Page 2 of 2) in pdf

Owner Operator Application Page 2

Page 2

Please initial in the space provided.

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I agree to notify the ATA Workers Compensation Fund within five (5) days of

hire, or contract signed, for new labor exposure to workers compensation that is

not covered by any current Occupational Accident policy.

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I agree to send in, on a timely basis, a monthly census for all owner operators,

lease purchase drivers, contract drivers (that drive equipment other than my

company owned trucks), or small fleet company drivers that my company uses.

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I declare that all of the information that I have provided for this application is true

and correct.

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I understand that if any of the information that I provided for this application is

found to be untrue, incorrect or misleading, my membership with the ATA

Workers Compensation Fund can be cancelled without prior notice and all

contributions and retrospective credits are forfeited; or the ATA Workers

Compensation Fund will retroactively pick up all remuneration for all employees,

owner operators, lease purchase drivers, contract drivers, and small fleet company

drivers that my company uses for workers compensation coverage purposes.

Signature ______________________________________________________

(this application must be signed by an officer of the company)

Title ______________________________

Date ______________________________

Owner Operator Application Page 2