CERTIFICATE OF ELECTION TO NOT MAINTAIN WORKER’S COMPENSATION COVERAGE
Click and hold your mouse to sign within the signature field below
If this is shown on your insurance, please submit a copy here as well.
1. Copy of Insurance2. Workers' Compensation (if this is shown on your insurance)3. Carrier Authority4. W9 or W8
Please provide the amount of each type of equipment that you OWN:
Please select as many states as necessary. To multiselect on 1) Windows: hold CTRL while you click as many states as necessary, 2) Mac: hold command while you click as many states as necessary.
("CARRIER"); collectively, the "Parties". ("Registered" means operated under authority issued by the Federal Motor Carrier Safety Administration (or its predecessors) within the U.S. Department of Transportation).
Express Logistics, Inc. – Home Office
Carrier Invoices Remit To Information