PASSENGER AUTHORIZATION AND RELEASE OF LIABILITY FORM by nbv20251

VIEWS: 307 PAGES: 4

									                                                        PASSENGER ACCIDENT
                                                            COVERAGE


               (Both Passenger and Driver should read carefully before voluntarily electing to sign)


COVERAGE:

This plan provides accidental death & dismemberment and accidental medical expense benefits to those pre-authorized
passengers who are injured while traveling with you while you are under dispatch. Coverage continues without interruption until
you are no longer under dispatch. This plan provides ACCIDENT Insurance only. It pays benefits for bodily injury; it does NOT
provide coverage for sickness. The coverage provided is NOT Workers’ Compensation Insurance. Further, this is a group
accident disability policy written in the state of Michigan.

“Passenger” means a person who is traveling in the truck without participating in its operation. It does not include operators,
drivers, crew members or helpers. A passenger must be approved by the company’s President or designated representative, and
must be named upon sign-up. “Under dispatch” means the Carrier has directed you to transport an authorized load on their
behalf.

This coverage for your passenger is provided at a cost of only $40/month or $250 annually. Coverage will begin automatically
once you return this form along with the “Passenger Authorization and Release of Liability Form” and premium is withheld by
the Carrier from your settlements.

BENEFIT HIGHLIGHTS:

A. Accident Death & Dismemberment. If a covered injury results in any of the following losses within one year after the date
of the accident, the plan will pay in one sum the indicated A,D&D Benefit amount:

        -    Loss of Life                                                      $ 250,000
        -    Loss of 2 or more members (hand, foot or of one eye)              $ 250,000
        -    Loss of one member (hand, foot or sight of eye)                   $ 100,000
        -    Loss of thumb & index finger of same hand                         $ 50,000

“Loss” as used above with references to hand or foot means the actual and complete severance through or above the wrist or ankle
joint. Loss of sight means irrecoverable loss of vision. Loss of thumb & index finger of the same hand means the complete and
permanent severance through or above the metacarpophlangeal joints. Your passenger’s loss of life benefit will depend upon
his/her age on the date of loss:

        -    Age < 69 on loss date                                             $ 250,000
        -    Age 70-74 on loss date                                            $ 150,000
        -    Age 75-79 on loss date                                            $ 100,000
        -    Age 80 or older on loss date                                      $ 75,000

B. Accident Medical Expense. If a covered passenger is injured and requires treatment by a licensed physician, employment of a
nurse, confinement in a hospital, x-ray examination, or the use of an ambulance, the plan will pay reasonable expense actually
incurred up to $100,000 subject to the Combined Single Limit. There is no deductible associated with the payment of the
Accident Medical Expense. However, the covered passenger must incur the expense(s) within one year following the date of the
accident. The plan will cover ground ambulance services up to a maximum of $250 per accident.

“Reasonable Expenses” means the usual and customary fee or charge for the services provided (and the supplies furnished) in the
area where provided or furnished. The services and supplies must be recommended and approved by a licensed physician.

C. Combined Single Limit. The maximum benefit payable is $250,000 per accident for any combination of benefits paid under
this plan. The most Cherokee Insurance Company will pay for any and all matters to one passenger is $250,000.

                                                               1
EXCLUSIONS:

No benefits will be paid for losses resulting from the following:

                •   Suicide or suicide attempts, while sane
                •   Self-destruction or attempts while insane
                •   Declared or undeclared war or an act of either
                •   Sickness or disease, except pyogenic infection caused by an accident, cut or wound.
                •   Dental treatment, except as a result of injury to sound natural teeth subject to a maximum of $100 per tooth
                    and a maximum of $1,000 per accident
                •   Replacement of eye glasses or eye exams for correction of vision or fitting of glasses unless an injury has
                    caused impairment of sight
                •   Hernia of any kind
                •   Pre-existing condition
                •   Heart, coronary, or any circulatory malfunction
                •   Operating, driving or acting as a crew member or helper
                •   Legal intoxication or being under the influence of a controlled substance

“Pre-existing condition” means a condition for which the passenger received medical treatment, or had treatment prescribed or
recommended, within 12 months before the passenger’s effective date of coverage. Such condition will not be considered pre-
existing if it causes loss after the passenger has been insured under this plan for 12 months.


  I am interested in signing up for the PASSENGER ACCIDENT COVERAGE for: (Please check one of the following)

________ $40/month                                                                          ________ $250 for annual coverage


Company:            ______________________________                      Unit Number/Driver Number: _______________________


Driver Name:        ______________________________                      Passenger Name:     ______________________________


Driver SSN:         ______________________________                      Passenger SSN:      ______________________________


Phone #:            ______________________________                      Passenger Age:      ______________________________


Driver Signature:   ______________________________                      Passenger Signature: ______________________________


Date Signed:        ______________________________                      Date Signed:        ______________________________


Coverage Start Date: _________________ (at 12:01 a.m.)                  Coverage Ending Date: _________________ (at 11:59 p.m.)


                                                     (Company Use Only)


Authorized By (Printed Name): _________________________________


Authorized By (Signature):        _________________________________


Date Signed:                      _________________________________
                                                                    2
                                PASSENGER AUTHORIZATION
                                           AND
                                RELEASE OF LIABILITY FORM

                (Both Passenger and Driver should read carefully before voluntarily electing to sign)


PASSENGER AUTHORIZATION:

This document constitutes authority by Universal Am-Can, Ltd. for


__________________________________________________ to be transported as the only passenger with
                  (PASSENGER)


__________________________________________________ for the exact period specified on this form.
                    (DRIVER)

This authorization shall end on the ending date and cannot be extended. Passenger is not authorized to operate the unit or
associated trailer (collectively “Equipment”) or to perform any labor associated with the Equipment or load at any time.

By signing this form, Passenger acknowledges and agrees that Passenger has been approved by Universal Am-Can, Ltd.’s
President or designated representative and Passenger is not an employee of Universal Am-Can, Ltd. or an independent contractor
providing goods or services to Universal Am-Can, Ltd. Passenger further acknowledges and understands that Universal Am-Can,
Ltd. will not pay any amount for any accident, injury, loss or damage arising out of or related to Passenger riding in the
Equipment, nor will Universal Am-Can, Ltd. provide a policy of insurance that provides coverage, including workers’
compensation coverage, for Passenger or passenger’s property.

RELEASE OF LIABILITY:

A. Driver’s Full Release of Liability.       In consideration for Universal Am-Can, Ltd.’s authorization to allow Driver’s spouse,
son, daughter, or any other passenger to ride in the Equipment, Driver, by signing this form, hereby releases Universal Am-Can,
Ltd. from any and all claims, liability, rights, actions, suits and demands, including any rights under a claim of loss of affection or
of consortium, whether in law or in equity, that Driver may have against Universal Am-Can, Ltd., including its affiliates,
employees, agents, officers, directors or successors. Moreover, this signed release may be pleaded by Universal Am-Can, Ltd. as
a counterclaim to or as a defense in bar or abatement of any action of any kind whatsoever brought, instituted, or taken by or on
behalf of Driver. Driver also understands that a separate, approved insurance policy must be secured by the driver at his or her
expense prior to being permitted to allow this passenger to occupy any equipment owned, leased or operated by Universal Am-
Can, Ltd.

B. Passenger’s Parent’s or Guardian’s Full Release of Liability.                   In consideration for Universal Am-Can, Ltd.’s
authorization to allow Passenger to ride in the Equipment, Passenger, by signing this form, hereby releases Universal Am-Can,
Ltd., with respect to the authorized transportation, from any and all claims, liability, rights, actions, suits and demands, including
any rights under a claim of loss of affection or of consortium, whether in law or in equity, that Passenger may have against
Universal Am-Can, Ltd., including its affiliates, employees, agents, officers, directors or successors. Moreover, this signed
release may be pleaded by Universal Am-Can, Ltd. as a counterclaim to or as a defense in bar or abatement of any action of any
kind whatsoever brought, instituted, or taken by or on behalf of Passenger. Passenger understands that the “rider program” must
be approved by Universal Am-Can, Ltd.’s Safety Director two weeks prior to my actual occupancy on or about any Equipment or
property owned, leased or operated by Universal Am-Can, Ltd.




                                                                  1
Driver Name:        ______________________________           Passenger Name:    ______________________________


Driver SSN:         ______________________________           Passenger SSN:     ______________________________


Phone #:            ______________________________           Passenger Age:     ______________________________


Driver Signature:   ______________________________           Passenger Signature: ______________________________


Date Signed:        ______________________________           Date Signed:       ______________________________


Coverage Start Date:         _____________________________ (at 12:01 a.m.)


Coverage Ending Date:        _____________________________ (at 11:59 p.m.)


Unit Number/Driver Number: _____________________________


                                               (Company Use Only)


Authorized By (Printed Name): _________________________________


Authorized By (Signature):    _________________________________


Date Signed:                  _________________________________




                                                         2

								
To top