Rider Waiver

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This form submission constitutes authority by A.D. Transport Express (hereinafter referred as “A.D.”) for the rider listed below to be transported as a passenger only. It does not in any form whatsoever constitute or imply employment or an employee of or at A.D.. Rider is not authorized and is specifically prohibited from operating the unit or associated trailer (collectively “Equipment”) or performing any labor or duties associated with the Equipment or load at any time for any reason. Rider is prohibited from entering any loading or unloading or vehicle maintenance area. (This waiver is only valid for one year from date of issue. A new waiver must be completed by the Rider and Driver annually. A copy or image of the Rider's legal identification is required.) . RIDER IS REQUIRED TO WEAR A SEAT BELT WHEN IN THE PASSENGER SEAT OR THE BUNK RESTRAINT WHEN IN THE BUNK.

Enter Full Legal Name

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Middle

Last

By submitting my name, I hereby specifically acknowledge that serious personal injuries and deaths frequently occur to passengers from motor vehicle accidents or incidents as well as from getting in and out of commercial vehicles. I acknowledge I am voluntarily exposing myself to these and other similar risks in exchange for authority to ride as a passenger in an A.D. owned or leased Equipment.

Personal Insurance Acknowledgement

I further acknowledge, I have personal medical and injury insurance. Should any injury occur, I will submit all claims and medical expenses to my personal insurance carrier. I acknowledge that A.D. will not be responsible for any medical costs associated with an injury I may sustain while being a rider in an A.D. owned or leased Equipment.
I do not have personal medical and/or injury insurance. I acknowledge that A.D. will not be responsible for any medical costs associated with an injury I may sustain while being a rider in an A.D. owned or leased Equipment. I will be solely responsible for any and all medical costs.

Personal Medical and Injury Insurance, if applicable

Please enter the name of your Insurance carrier.

Driver's Name

Please provide the name of the A.D. Transport Express driver you will be riding with.

Signature

In consideration for A.D.’s authorization to allow me to ride as a passenger, by signing above, I hereby release A.D. from any and all claims, liability, rights, actions, suits and demands, including any rights under claim of loss of companionship, affection or consortium, where in law or in equity, that Rider may have now or later, known or unknown, against A.D., including its insurers, affiliates, employees, agents, officers, directors or successors, during the authorized trip. Moreover, this signed Release may be pleaded by A.D. as a counterclaim to or as a complete defense in bar or abatement of any action of any kind whatsoever brought, instituted, or taken by or on behalf of Rider. Rider also agrees where allowed by law any loss and this Release shall be governed by the laws of Michigan.

Rider's legal identification

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Please attach a copy or image of the Rider's legal identification