Become A Member Please fill out the enrollment application below and someone will be in touch with you shortly. Truckers Benefit Association Membership Form Referred by TBA Member?* Yes No His/Her Member NumberYour Personal InformationName* First Last Date of Birth* MM slash DD slash YYYY DOT NumberYour Contact InformationCompany Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Cell Phone NumberEmail Address* Motor Carrier InformationCarrier Name Carrier Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Carrier PhoneCarrier DOT NumberCarrier Contact Person First Last Membership AgreementMembership fee is $144 for one year. I hereby apply for membership in Truckers Benefit Association ("TBA") an association for truck drivers who are not employees of a motor carrier. I understand my membership in TBA is based on maintaining my status as an independent truck driver. I understand that my membership in TBA shall immediately terminate in the event I fail to pay the monthly membership dues. I understand that to receive insurance coverage I must complete a separate application for coverage, comply with the terms, and be accepted into the insurance purchasing group program. I certify I am an independent contractor driving a truck which I own or lease. I authorize the above identified motor carrier, if applicable, to make settlement deductions from the funds that are due for my services for timely payment of my monthly TBA dues and other charges I may authorize. I authorize TBA to receive funds from either the motor carrier or me and to remit such funds to the appropriate insure or authorized insurance professional for payment of my insurance premiums. If I contract with another motor carrier, I understand and agree that I must complete and immediately forward to TBA the new motor carrier information, along with the appropriate membership dues and other payments as required.* I have read, understand, and agree to all the terms and conditions of a membership in TBA Date MM slash DD slash YYYY Δ
