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OccAcc FFM-Hub 2 Occupant

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Agency: TrueNorth Companies LLC - Last Mile - Captive (2351)
Please print
Name: ___________________________________________________________ Male: ____________ Female: ____________
Street Address:_____________________________________ City: ______________________ State: ______ Zip: _________
Social Security Number: _______________ Date of Birth: ___________ E-mail Address: _____________________________
Home Telephone Number: _____________________________ Cell Telephone Number: ______________________________
Name of Beneficiary: ______________________________ Relationship of Beneficiary: _______________________________
DL Number: _____________________________________________ Number of Years Experience: ____________________
Contracted by (Name of Company): ________________________________ Effective Date of Contract: __________________
Street Address: _____________________________________ City: ______________________ State: ______ Zip: ________
Policyholder or Motor Carrier Telephone Number: _________________________ Fax Number: __________________________
Policyholder or Motor Carrier E-Mail Address: _______________________________________________________
Are you an Owner-Operator? Yes
No
If yes, is the Certificate of Title in your name? Yes
If no, are you a: Co-Owner
Co-Driver
No
Team Driver
Contract Driver
Scheduled Co-Driver
Leased Driver
Authorized Passenger
Casual Laborer
or Other__________________________________
Paid by: 1099
W-2
I understand and hereby acknowledge the following:
1.
This coverage is not Workers’ Compensation Insurance or for any other purpose except occupational accidents (unless nonoccupational benefits apply). I nor the Policyholder above can become participants in the Workers’ Compensation system by
purchasing this insurance;
2.
This is a limited benefit policy. It does not provide comprehensive health insurance coverage. It does not satisfy the
requirements of minimum essential coverage under the Affordable Care Act or its equivalent;
3.
This policy does not cover pre-existing conditions, unless otherwise endorsed;
4. To the best of my knowledge and belief, all information I have provided is true and complete. I understand my information is
protected by privacy laws and will be released only in accordance with these laws;
5. I certify that I meet the eligibility requirements under the Policy. I understand that if I am not eligible, no benefits will be paid and
this coverage will be cancelled. I further understand that coverage terminates on the date the policy is terminated, or I am no longer
under contract with the above mentioned policyholder, or my premium is not paid;
6. I authorize any 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 records, including any medical records to furnish such
information or copies of records to Great American Spirit Insurance Company, the Policyholder or the Policyholder’s designee. A
photographic copy of this authorization shall be as valid as the original
7. I understand that coverage becomes effective when this application has been received and approved by Great American Spirit
Insurance Company or its authorized agent.
I accept the insurance elected above voluntarily. If at a later date I wish to participate in a coverage I have not elected, I
understand that my coverage is subject to the terms and conditions of the policy and acceptance by the Insurance
Company. I understand I may be required to provide evidence of insurability at my own expense. If premiums are to be paid
by payroll / account deduction, I authorize the necessary amount from my earnings/checking or savings account to be
deducted.
Applicant's Signature _______________________________________________________ Date Signed ________________________
OCC2002 (Ed. 07/17)
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Agency: TrueNorth Companies LLC - Last Mile - Ca
GREAT AMERICAN SPIRIT INSURANCE COMPANY
OCCUPATIONAL ACCIDENT INSURANCE ENROLLMENT FORM
Policyholder:
Forward Air Final Mile, LLC dba Forward Final Mile
9440 Wright Brothers Ct. SW
Cedar Rapids,IA 52404
Monthly Premium:
Policy Number:
$297
OA4037013
Classes of Eligible Persons:
Class
Description of Class
1
All Owner-Operators between the ages of 23-75 who are under contract with the Policyholder who have
enrolled for coverage under this Policy.
5
All Casual Laborers of the Owner-Operator or Contract Driver who have enrolled for coverage under this
Policy.
OCC2002 (Ed. 07/17)
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Agency: TrueNorth Companies LLC - Last Mile - Ca
Schedule of Benefits: Coverage
Class 1: Owner-Operators
DESCRIPTION OF BENEFITS:
OCCUPATIONAL
NON-OCCUPATIONAL
ACCIDENTAL DEATH BENEFIT
Principal Sum:
$50,000
$10,000
Commencement Period:
365 Days
365 Days
SURVIVOR'S BENEFIT
Principal Sum:
$200,000
$0
Monthly Benefit Amount:
$2,000
$0
Maximum Number of Months:
100
0
ACCIDENTAL DISMEMBERMENT &
PARALYSIS BENEFIT
Principal Sum:
$250,000
$10,000
Commencement Period:
365 Days
365 Days
Maximum Number of Months:
24
12
Monthly Benefit Amount: Percentage of Principal Sum for Covered Percentage of Principal Sum for Covered
Loss, divided by the Maximum number of Loss, divided by the Maximum number of
Months
Months
ACCIDENT MEDICAL EXPENSE BENEFIT
Scope of Coverage:
Excess
Excess
Maximum Benefit Amount:
$1,000,000
$10,000
Maximum Benefit Period:
104 Weeks
104 Weeks
Commencement Period:
90 Days
90 Days
Deductible:
$0 Per Accident
$0 Per Accident
Coinsurance: 100% of Usual and Customary Charges
100% of Usual and Customary Charges
Maximum Benefit for Ambulance Services:
No Sublimit Applies
No Sublimit Applies
Maximum Benefit for Dental Expenses:
$5,000 Per Accident
$1,000 Per Accident
$25,000 Lifetime Maximum
$10,000 Lifetime Maximum
Maximum Benefit for Physical Therapy,
No Sublimit Applies
No Sublimit Applies
Occupational Therapy and Chiropractic Care:
TEMPORARY TOTAL DISABILITY
BENEFIT *
Benefit Percentage:
Maximum Weekly Benefit Amount:
Minimum Weekly Benefit Amount:
Maximum Benefit Period:
Waiting Period:
Commencement Period:
CONTINUOUS TOTAL DISABILITY
BENEFIT *
Monthly Benefit Amount:
70% of Average Weekly Earnings
$600
$150
104 Weeks
7 Days Retroactive
365 Days
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Up to a Maximum of $2,580
Not Covered
Subject to all policy terms and provisions
Maximum Benefit Period **:
Social Security Retirement Age
Not Covered
Waiting Period: Equals the Maximum Benefit Period for
Not Covered
Temporary Total Disability
$1,000,000 per Insured Person
COMBINED SINGLE LIMIT
$2,000,000 per Accident
AGGREGATE LIMIT
* Temporary & Continuous Total Disability are subject to the lesser of: 70% of Average Weekly Earnings or the Weekly/Monthly
Benefit Amount Shown
** Social Security Retirement Age (SSRA) will vary depending upon the Insured Person’s date of birth. If the Insured Person reaches
his/her SSRA before satisfying the waiting period, he/she may not qualify for Continuous Total Disability Benefits.
OCC2002 (Ed. 07/17)
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Agency: TrueNorth Companies LLC - Last Mile - Ca
Optional Additional Benefits
Class 1: Owner-Operators
DESCRIPTION OF BENEFITS:
Hemorrhoids Benefit
Maximum Accidental Medical Benefit Amount:
OCCUPATIONAL
NON-OCCUPATIONAL
$50,000
Subject to a Maximum Benefit Period of
10 weeks
Deductible:
$0 Per Accident
Maximum Temporary Total Disability Benefit
10 Weeks
Period:
Waiting Period:
7 Days
Maximum Per Insured Person Benefit Amount:
$50,000 combined lifetime Maximum
Benefit per Insured Person
Hernia Benefit
Maximum Accidental Medical Benefit Amount:
$50,000
Subject to a Maximum Benefit Period of
10 weeks
Deductible:
$0 Per Accident
Maximum Temporary Total Disability Benefit
10 Weeks
Period:
Waiting Period:
7 Days
Maximum Per Insured Person Benefit Amount:
$50,000 combined lifetime Maximum
Benefit per Insured Person
Occupational Cumulative Trauma Benefit
Not Covered
Maximum Accidental Medical Benefit Amount:
Not Covered
$10,000
Subject to a Maximum Benefit Period of
10 weeks
Deductible:
$0 Per Accident
Maximum Temporary Total Disability Benefit
10 Weeks
Period:
Waiting Period:
7 Days
Maximum Per Insured Person Benefit Amount:
$10,000 combined lifetime Maximum
Benefit per Insured Person
Pre-Existing Conditions Benefit
Maximum Benefit Amount:
$15,000
Severe Burn Benefit
Commencement Period:
365 Days
Principal Sum: Included in Accidental Dismemberment
Principal Sum
OCC2002 (Ed. 07/17)
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
365 Days
Included in Accidental Dismemberment
Principal Sum
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Agency: TrueNorth Companies LLC - Last Mile - Ca
Schedule of Benefits: Coverage
Class 5: Casual Laborers
DESCRIPTION OF BENEFITS:
OCCUPATIONAL
ACCIDENTAL DEATH BENEFIT
Principal Sum:
$50,000
Commencement Period:
90 Days
SURVIVOR'S BENEFIT
Principal Sum:
$200,000
Monthly Benefit Amount:
$2,000
Maximum Number of Months:
100
ACCIDENTAL DISMEMBERMENT &
PARALYSIS BENEFIT
Principal Sum:
$250,000
Commencement Period:
365 Days
Maximum Number of Months:
24
Monthly Benefit Amount: Percentage of Principal Sum for Covered
Loss, divided by the Maximum number of
Months
ACCIDENT MEDICAL EXPENSE BENEFIT
Scope of Coverage:
Excess
Maximum Benefit Amount:
$1,000,000
Maximum Benefit Period:
104 Weeks
Commencement Period:
90 Days
Deductible:
$0 Per Accident
Coinsurance: 100% of Usual and Customary Charges
Maximum Benefit for Ambulance Services:
$0
Maximum Benefit for Dental Expenses:
$5,000 Per Accident
$25,000 Lifetime Maximum
Maximum Benefit for Physical Therapy,
No Sublimit Applies
Occupational Therapy and Chiropractic Care:
TEMPORARY TOTAL DISABILITY
BENEFIT *
Benefit Percentage:
Maximum Weekly Benefit Amount:
Minimum Weekly Benefit Amount:
Maximum Benefit Period:
Waiting Period:
Commencement Period:
CONTINUOUS TOTAL DISABILITY
BENEFIT *
Monthly Benefit Amount:
70% of Average Weekly Earnings
$600
$150
104 Weeks
7 Days Retroactive
90 Days
NON-OCCUPATIONAL
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Up to a Maximum of $2,580
Not Covered
Subject to all policy terms and provisions
Maximum Benefit Period **:
Social Security Retirement Age
Not Covered
Waiting Period: Equals the Maximum Benefit Period for
Not Covered
Temporary Total Disability
$1,000,000 per Insured Person
COMBINED SINGLE LIMIT
$2,000,000 per Accident
AGGREGATE LIMIT
* Temporary & Continuous Total Disability are subject to the lesser of: 70% of Average Weekly Earnings or the Weekly/Monthly
Benefit Amount Shown
** Social Security Retirement Age (SSRA) will vary depending upon the Insured Person’s date of birth. If the Insured Person reaches
his/her SSRA before satisfying the waiting period, he/she may not qualify for Continuous Total Disability Benefits.
OCC2002 (Ed. 07/17)
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Agency: TrueNorth Companies LLC - Last Mile - Ca
Optional Additional Benefits
Class 5: Casual Laborers
DESCRIPTION OF BENEFITS:
Hemorrhoids Benefit
Maximum Accidental Medical Benefit Amount:
OCCUPATIONAL
NON-OCCUPATIONAL
$50,000
Subject to a Maximum Benefit Period of
10 weeks
Deductible:
$0 Per Accident
Maximum Temporary Total Disability Benefit
10 Weeks
Period:
Waiting Period:
7 Days
Maximum Per Insured Person Benefit Amount:
$50,000 combined lifetime Maximum
Benefit per Insured Person
Hernia Benefit
Maximum Accidental Medical Benefit Amount:
$50,000
Subject to a Maximum Benefit Period of
10 weeks
Deductible:
$0 Per Accident
Maximum Temporary Total Disability Benefit
10 Weeks
Period:
Waiting Period:
7 Days
Maximum Per Insured Person Benefit Amount:
$50,000 combined lifetime Maximum
Benefit per Insured Person
Occupational Cumulative Trauma Benefit
Not Covered
Maximum Accidental Medical Benefit Amount:
Not Covered
$10,000
Subject to a Maximum Benefit Period of
10 weeks
Deductible:
$0 Per Accident
Maximum Temporary Total Disability Benefit
10 Weeks
Period:
Waiting Period:
7 Days
Maximum Per Insured Person Benefit Amount:
$10,000 combined lifetime Maximum
Benefit per Insured Person
Pre-Existing Conditions Benefit
Maximum Benefit Amount:
$15,000
Severe Burn Benefit
Commencement Period:
365 Days
Principal Sum: Included in Accidental Dismemberment
Principal Sum
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
The list of benefits is only a brief description of the actual coverages. Certain exclusions and limitations do apply. For complete details
please refer to your policy. In the event of any conflict between the information listed here and the actual policy, the insurance policy
will govern in all cases.
Social Security Retirement Age (SSRA) will vary depending upon the Insured Person’s date of birth. If the Insured Person reaches
his/her SSRA before satisfying the waiting period, he/she may not qualify for Continuous Total Disability Benefits.
OCC2002 (Ed. 07/17)
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