Owner/operator request for insurance

BLANKET OCCUPATIONAL ACCIDENT INSURANCE Please review your Description of Coverage for benefit details.
 
BENEFICIARY DESIGNATION – ACCIDENTAL DEATH BENEFIT
__________________________ ___________________________ ___________________ ____________________
Beneficiary Name Beneficiary Address Relationship to Insured Beneficiary SS#
 
 
 
By signing this Owner/Operator Enrollment Form,  
 
I hereby declare and state that:  
1. I am not an employee or eligible for Workers’ Compensation from the Participant Sponsor. I request coverage under the 
Sponsoring Association's group Occupational Accident policy;
2. I am electing to exclude myself from Workers' Compensation coverage as permissible under the laws of my state; 
3. I am a member of the USA Trucking Association;
4. I hereby understand and agree that eligibility for this program is limited to eligible Classes listed above and I further 
agree to the terms outlined in the above items; 
5. I qualify for coverage under the Eligible Class as checked above;
6. I request coverage under the Sponsor’s USA Trucking Association group Occupational Accident policy; 
7. I understand this insurance will become effective the date this Enrollment Form has been received and approved by 
Pan American Life Insurance Company or their authorized representative; 
8. I grant permission to the Participant Sponsor to deduct such payments as may be required for the insurance provided by 
the policy; 
9. I hereby grant a limited power-of-attorney to Association with the authority to initiate cancellation of my Occupational 
Accident 
coverage effective the same date I am no longer eligible under this Program; and
10. The beneficiary designation above shall void and supersede any previous designation by me. I reserve the right to 
change the beneficiary shown above by completing and submitting a signed Change of Beneficiary Form; 
11. I understand that the insurance as applied for is based upon my written statements and answers to the above questions; 
and 
12. I attest that all statements made in this Request For Insurance are true and accurate to the best of my knowledge.
Any person who knowingly, and with intent to injure, defraud, or deceive an insurance company, submits an 
application and/or files a statement of claim containing any false, incomplete, misleading information is guilty of 
insurance fraud which is a felony.