Coverages

Occupational Accident Insurance


Occupational Accident Insurance
Quick Quote

Coverage:
Accidental Medical Expence Benfits
0 Deductable 104 weeks payment period

$1,000,000.00
Accidental death & Dismemberment
($50,000. Lump sum - $2,000 Monthly)

$250,000
Long term Disability
(pays to Age 70 - then social security off set)

70% up to $500.00 per Week
Monthly Premium
General Freight
(Box truck - Box Trailer)

 $168.00
Flat bed, Dumps, Sand & Gravel, Auto Haulers

 $189.00
Tankers - Gasoline - Chemicals - Oil 

 $208.00
Optional Coverage
Passenger Accident coverage
Passenger must be age 18 or older

$5
Contigent Liability
Pays work comp benfits if contract driver
deemed by court to be an employee.

 $11
Total monthly premium
  
Deposit Premium
Total to Bind Coverage


Application
Occupational Accident Insurance
Name:
First Name:   Last Name:  
Address:
Street: City:
State: Zip:
Date of birth: Social Security No:
Phone Number: Cell Phone:
Fax Number: Pager Number:
Email: Gender:
Beneficiary: Relationship:
Industry Design: # Years Experience:

Contacted By: Contact Name:
Address:
Street: City:
State: Zip:
Phone: Fax:
Email: Fedral ID/DOT #:
Commodities Hauled: Type of Trailer:

Yes answers may require additional information and are subject to approval.
1. Have you ever filed a claim for workers' compensation or
    any occupational related injury
2. Do you lift heavy objects, load or unload?
Have you ever treated or had any indication of:
3. Back, neck, or spinal injury?
4. Neuritis, Sciatica, Arthritis, or Disorder of the muscle or bone?
5. Have you beeen treated for Alcoholism or a drug habit?
7. Are you presently using any presciption medication?
8. Are you currently paid as a W-2 employee?
Explanaiton of Yes answers
Identify the question # to any answer. Explain diagnosis, dates duration, insurance provided,
medical treatment, doctor's name, address and telephone/fax number.
  
I certify that if coverage is issued, it could be voided and claims denied if information has been withheld or misrepresented and I certify that all information on this form is complete and truthful.

I am a contractor paid by a 1099 tax form not as a W-2 employee.