MEMBERSHIP REGISTRATION FOR NORTHAMERICAN TRANSPORTATION ASSOCIATION

NTA Membership Registration

NORTHAMERICAN TRANSPORTATION ASSOCIATION
In applying for membership with NorthAmerican Transportation Association Inc. (NTA Inc) for the procurement of any of the association’s programs, I or We, are desirous of becoming a member of NTA and understand that the membership in NTA Inc. is limited to and made up entirely of separate transportation related companies consisting of at least one owner. NTA offers its members a free subscription to NTA’s High-Way Hi-Lites,” an electronic weekly newsletter & “10-4 Magazine”, a monthly electronic magazine.

We understand and agree that we must have on file a current credit card and/or electronic check payment form (ACH) at all times.

We understand that some benefits or services are for MEMBERS ONLY. To help new member companies establish a credit line, we understand that all accounts are reported to our in-house credit bureau on a monthly basis.

THIS FORM MUST BE SIGNED by an authorized representative from each company and returned with the applicable fees to NTA Inc. before any services or benefits can be started. Please keep copies of this form for your record keeping as proof of your association membership with NTA Inc.
What type of NTA services are you interested in?*

MembershipMembership and Occupational Accident InsuranceMembership and ELD

NTA Membership Registration
Date

MonthDayYear
Date
Name of Company or Individual*
Company Contact*
Mailing Address*
City*
State*
Abbreviation
Zipcode*
Is your Physical Address the same as your Mailing Address?*

YesNo
Physical Address
City
State
Zipcode
US DOT Number*
MC Number
EIN or SSN*
Phone*
Fax
Email*
example@example.com
Website
Total number of employees you will enroll
Total number of Independent Contractors you will enroll*
Based on your latest MCS-150
By signing below, you acknowledge that you are legally signing this document.

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NTA Membership Dues Rate Schedule for Motor Carriers & Independent Contractors. Membership includes a Free subscription to Hi-Way Hi-Lites (association electronic newsletter) and a Free subscription to 10-4 Magazine.

# of Drivers	Fee x Driver x 12 Months
1	$100
2-10	$4.50 Per Driver x 12 Months
11-20	$4.00 Per Driver x 12 Months
21-50	$3.50 Per Driver x 12 Months
51-100	$3.00 Per Driver x 12 Months
101-200	$2.50 Per Driver x 12 Months
201-500	$2.00 Per Driver x 12 Months
501 and Over	$1.50 Per Driver x 12 Months

Must be secured by either a credit card or an electronic check payment. Membership is Non-Refundable.

NTA Membership Dues (annual)
Calculation MemDues

Occupational Accident Insurance Plan Disclosure

Please read carefully before signing
Each Motor Carrier with a FMCSA MC number and each Independent Contractor (IC) is considered to be a separate company. This is based on certain States that have the “A, B, C Rule” plus Dept. of Labor (DOL) & Internal Revenue Service (IRS) regulations and each entity is required to submit an NTA Membership application to gain access to our Master Policy.

Important: NTA dues will be billed by NorthAmerican Transportation Association and Insurance premiums will be billed by NTA Administrative Services. NTA uses Intuit QuickBooks as its billing protocol. Be advised that any business with NTA is a credit account reported to a division of Equifax. See website for the required document forms. On ALL forms “Your name constitutes your Signature.”

Membership is necessary to prove that the individual to be covered is in reality an Independent Contractor in the eyes of the Dept. of Labor (DOL) and the various State courts using the “A, B, C Rule” i.e., California and to gain access to our Benefits and Services.

Membership for a Motor Carrier is based on the number of drivers shown on their last MCS-150 filing. Membership for Independent Contractors starts at $100 for the sole proprietor. Memberships are paid annually and are not refundable.

This Plan Disclosure Form MUST be signed & Submitted by the party who is responsible for premium payment.

Please note that coverage always starts on the 1 of each month. There is no prorating. Policy is issued to the individual. Coverages starting after the 1 of the month must be accompanied by two months premiums, as the premiums must be paid in advance two (2) weeks before the premium is due.

Once a Certificate/Policy is issued the premium is considered earned. These Plans are considered long term coverages; therefore, a 30 day Written Notice of Cancellation is required. Please read Section II of your policy “Effective Dates and Termination Dates” for more specific information of your rights and responsibilities.

All billing is done on the 15th of each month prior to the premium period and all automatic ACH and/or Credit Card deductions are done on the 16 of each month. There is a $5.00 admin fee added to cover each personal policy issued.

After your coverage is in place, you will have the following options of paying your premiums. 1) pay by ACH deduction ($5.00 fee), 2) pay by credit card (5% charge with a $5 minimum charge applies), or with Approved credit options 3 & 4. 3) pay on-line, and 4) by mail.

If you need a Certificate Holder listed on your Notice of Coverage, please make sure we have the complete information i.e., Name, Address, Tel # and email added to the Great American Application.

If you have any further questions, you may call, email or go to www.ntassoc.com and review the 12-page brochure in the privacy of your home. ****************************************************************************************

NOTICE: Credit Card regulations require that you have read this Plan Disclosure and understand by printing and/or signing below you have given your affirmative consent under the ESIGN Act, Sec 101(c1) (c) This form MUST be submitted along with your application for coverage.
By signing below, you acknowledge that you are legally signing this document.*

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Occupational Accident Insurance Loss History Affidavit

Must be completed by all prospective drivers
I, Company Owner* , do hereby certify and swear that Company Name* has incurred 0 * injuries within the last 36 months.
If you had injuries within the last 36 months, please list Year, Employee, Cost, Injury and Status below:
If there have been no injuries, write NONE in the field above.
Explanation: Why can't loss runs be provided or if an individual claim amount exceeds $15,000.00
If you have had Workers Compensation coverage through another company within the last 36 months, please list below:
Note: This affidavit must be submitted with the New Client Profile Sheets when loss runs are not available. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information with the purpose of avoiding or reducing the amount of premiums for workers' compensation coverage or crucial information pertinant to the computation and application of an experience rating modification factor, is guilty of a felony of the third degree or as otherwise punishable by law. IGI rev.2/05
By signing below, you acknowledge that you are legally signing this document.*

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Title/Position
Date

MonthDayYear
Date

Drivers Occupational Accident Insurance

Please fill out the entire form as accurately as possible
Which Plan are you interested in?*

Plan A, $1,000,000 of coverage for $147 per MonthPlan B, $500,000 of coverage for $126 per Month
Insurance Premium Cost
When would you like Insurance Coverage to begin?*

MonthDayYear
Date
Please note that Great American does NOT prorate their Insurance Policies.

If you need your insurace coverage right away, we are happy to expedite your insurance policy. However, you will be billed for both this month as well as next month, since insurance is billed in advance on the 15th of the month for the following month.

We generaly recommend beginning insurance coverage at the beginning of the month to avoid the additional billing of the non-prorated insurance premium.
Would you like to go ahead and start your Insurance Coverage right away?*

Yes, please set me up as soon as possibleNo, I am fine waiting until the first of the next month
Thank you, we will begin Occupational Accident Insurance coverage on
Driver Name*
Date of Birth*
Address*
City*
State*
Zip Code*
Home Phone
Cell Phone*
Beneficiary Name*
Please type 'None' if you have no desired Beneficiary
Relationship
Please type 'None' if you have no desired Beneficiary
Type of Driver*

Owner Operator
Indicate type of driver

Other, including an authorized passengerOther, including an authorized passenger
Date of Hire

MonthDayYear
Date
CDL or DL Number*
EIN or SSN
Unit Number/VIN#
Commodity Hauled*
Paid by: 1099W-2
Contracted By
Motor Carrier Name & Address
Please type 'Same' if you are your own Motor Carrier. Otherwise, please list the carrier who will hold your Notice of Certificate of insurance.
Agent Name
Agent Phone
Agent Address
I Accept the Occupational Accident insurance offered by the above listed Policyholder or Participating Motor Carrier. I understand that coverage becomes effective when this application has been received and approved by Great American Insurance Company or its authorized agent. I understand that I will no longer be eligible for coverage upon my 70th birthday and that coverage will therefore cease. I further understand that coverage terminates on the date the policy is terminated; or I am no longer under contract with the above mentioned motor carrier; or my premium is not paid. I also understand that coverage may be available on an individual policy subject to underwriting guidelines in effect at termination of the above policy.
By signing below, you acknowledge that you are legally signing this document.*

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Date

MonthDayYear
Date
Medical Information Authorization: I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related organization, institution or person that has any records, including any medical history for the above named person facility, insurance company or any other representatives. A photographic copy of this authorization to furnish such information or copies of records to the insurance companies association or its shall be as valued as the original.
By signing below, you acknowledge that you are legally signing this document.*

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Date

MonthDayYear
Date
FLORIDA STATUTE 817.234(1)(b)

"Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree."

NEW MEXICO STATUTE 59A-16C-8

“Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.”

OHIO INSURANCE CODE 3999.21

“Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insured, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.”

Electronic Check or Credit Card Authorization
Please Select a Payment Type:*

Automatic ACH DeductionAutomatic Credit Card
Initial Box to designate type of payment. ALL Payments must be made no later than the 16th of each month.

Will pay on-line as shown on Invoice.Will pay by check.
Name on Check
Full Mailing Address
Type of Account

CheckingSavings
Bank Routing Number
Bank Account Number
Email Address for Electronic Receipt
example@example.com
Card Holder Name
Card Holder Address
Card Type

VisaMasterCardDiscover
Expiration Date

MonthDayYear
Date
First 8 Digits of Credit Card
For Security Purposes, Card Number is Split in Two
Last 8 Digits of Credit Card
For Security Purposes, Card Number is Split in Two
3 Digit Security Code
Found on the back of Card
E-mail Address for electronic receipt
example@example.com
By signing here, you acknowledge you are legally signing this document and authorize the NTA *

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Checkout
Total Charges for NTA Membership
Your billing invoice will be from NorthAmerican Transportation Association
Total Charges for Occupational Accident Insurance
Your billing invoice will be from NTA Administrative Services
Estimated Total Charges for ELD
An NTA Representative will contact you shortly with a finalized bill including Shipping, Handling, and State and Local taxes.
Amount Authorized CC
FOR REFERENCE ON THE CREDIT CARD ACH FILE
Amount Authorized ACH
FOR REFERENCE ON THE CREDIT CARD ACH FILE
Grand Total all Charges
Thank you for your business and Welcome to the NTA!

Contact us with questions: 800-805-0040 or email info@ntassoc.com

You will be receiving a welcome email and will see billing charges on your payment account shortly. The NTA is happy to provide our Members with free Safety Consulting and business advice. Please don't hesitate to contact us if you have questions and need information. One of our NTA representatives will be happy to provide concierge service to your fleet needs.
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NTA Membership Registration

NTA Membership Registration

Occupational Accident Insurance Plan Disclosure

Occupational Accident Insurance Loss History Affidavit

Drivers Occupational Accident Insurance

NTA ELD Order Form

Please choose from one of three ELD Plans below:

Electronic Check or Credit Card Authorization

Checkout