B-OCCACC-TA-ENROLL (6/13)
Pan-American Life Insurance Company
New Orleans, Louisiana
BLANKET ENROLLMENT FORM
Sponsoring Association: USA Trucking Association
_____________________________________________
___________________________________
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.
Mohamedelfateh Ibrahem Mohamedhaj
male
1064 Alabama Dr Apt 101
Herndon
VA
20170
03/03/1960
213-57-4701
571-324-5714
02/18/2022
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