By clicking the “I Agree” button below, I agree to all of the following terms and conditions of membership.

I certify that I am an independent contractor, paid via a 1099 tax form, not a W-2 employee. I certify that to the best of my knowledge and belief, all information on this Form and my Membership Signup Form is complete and truthful. I accept that premium will be refunded and no claims will be payable if, based on the information supplied, I am not eligible for coverage. I understand that no coverage will be in effect until I receive written notice from the Association.

I also understand and hereby state that this coverage being applied for is not a contract for Statutory Workers’ Compensation Insurance, and neither I nor my carrier become participants in the Workers’ Compensation system by purchasing this insurance.

I hereby accept the insurance plan that I have selected above. I agree to be responsible for all earned premiums and any specified deposit amount, which I acknowledge and accept are non-refundable. I authorize The Association for Delivery Drivers and its agents to apply all monies paid for this purpose, and to initiate debit entries and, if necessary, credit entries and adjustments for any debit entries in error to my Bank Account, Credit or Debit Card Account designated above, and to debit and/or credit the same to such account in amounts that correspond to the benefit and payment plans I have selected.

I understand and agree that a $25.00 fee will be charged if there are insufficient funds in my account and/or my cardholder declines payment. Payment options may be revoked in the event of more than two such fees within any 12-month period. I understand that coverage will cease in the event of nonpayment of premium in accordance with my policy provisions.

I understand that I have authorized recurring billing for my insurance premium. I also understand that in order to cancel my insurance coverage and stop premium billings, I must complete the Cancel Membership and/or Insurance form accessible from any page of the Association website.

Member acknowledges and agrees that in exchange for using a Contracting Company Code (CCC) to save on insurance premiums, Member authorizes the CCC’s granting carrier to receive Member’s Certificate of Insurance and view the coverage(s) Member has selected and the dates and status of Member’s insurance.

Any person who knowingly and with intent to defraud any insurance company or companies or other person, files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and will be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

IF THE INFORMATION PROVIDED BY ME IS FRAUDULENT, THE INSURER HAS THE RIGHT TO RETURN PREMIUM AND CANCEL COVERAGE.

In order to verify the information provided by me, I give the Insurer authority to examine the records that are maintained by any motor carrier that I am under contract with. By initiating the purchase of insurance below, I also authorize any shipper, consignee, carrier, customer, insurance company, licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company or any other organization, institution or person that has any documentation or records, including any medical records, to furnish such information or copies of records to the insurer, the Association for Delivery Drivers, or the Association’s insurance broker or other designee for the purpose of implementing this insurance contract. A reproductive image of this authorization and acknowledgement shall be as valid as the original.