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.
Mohamedelfateh
02/18/2022
