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ENROLLEE INFORMATION SHEET AND BENEFICIARY DESIGNATION
Enrollee Information: (please print)
Address :__________________________________________________________ PLAN C
City :___________________________ State:________ Zip:____________
Date of Birth :___________________________
Gender Male Female
Home Telephone Number :___________________________
Cell Phone Number :___________________________
Email Address :___________________________
Relationship to Beneficiary :___________________________
CDL Number :___________________________
Number or Years Experience :___________________________
Contract Information: (please print)
If owner operator, name of Motor Carrier to whom contracted :_____________________________________________
If contract driver, name of Owner/Operator to whom contracted :_____________________________________________
Address of Motor Carrier or Owner/Operator shown above :_____________________________________________
City_____________________________________ State_____________ Zip_________________________
Telephone number of Motor Carrier or Owner/Operator shown above :_______________________________
Fax number of Motor Carrier or Owner/Operator shown above :_______________________________
Email Address of Motor Carrier or Owner/Operator shown above :_______________________________
Effective Date of Contract :___________________________
General Information: (please print)
Are you an Owner/Operator? Yes No If yes, is the Certificate of Title in your name? Yes No If no, are you
a: Co-Owner Leased Driver Contract Driver Team Driver Employee
Number of auto accidents within the past 3 (three) years ____________
Do you drive for another person? Yes No Do you load or unload? Yes No
Do you attach or detach any trailers? Yes No Do you use tarps or chains? Yes No
What type of transmission do you drive? Automatic Manual
Do you drive? Long Haul (≥ 100 miles per trip) Short Haul (< 100 miles per trip)
Do you haul or drive (check all that apply) Livestock Tankers Dump Trucks Garbage/Refuse
Chemicals Intermodal Dump Trailers (side or end dump) Furniture Moving & Storage GVW < 20,000 lbs.
What other duties do you perform? _______________________________________________________________________
Are you covered under any medical plan? Yes No If yes, please state :_______________________________
I understand and hereby state:
1. The Occupational Accident coverage provided is not a contract for Statutory Workers’ Compensation Insurance and neither
the Motor Carrier above or I become participants in the Workers’ Compensation system by purchasing this insurance.
2. I certify to the best of my knowledge and belief that all information on this form is complete and truthful.
3. 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 Zurich American Insurance Company, the Motor Carrier, or the Motor
Carrier’s designee. A photographic copy of this authorization shall be as valid as the original.
4. I am an independent contractor and receive a 1099 tax form and not a W-2 tax form as an employee.
If premiums are not being paid directly by the enrollee, I authorize the above named Motor Carrier or Owner/Operator with whom
I have a contract, to take monthly deductions, equal to my premiums, from my settlement account on my behalf, and to remit these
funds to Zurich American Insurance Company or its appointed agent. I understand that the cost of the insurance is my sole
obligation and responsibility regardless of the above arrangement for premium payment.
Enrollee Signature:______________________________________ Date:____________________________
U-OA-317-A CW (05/06) REVISION (09/07) 1 of 2
Zurich-American OCCUPATIONAL ACCIDENT Administered By:
(9/1/07) PLAN C 5Star Specialty Programs
I hereby enroll for Occupational Accident insurance under the Group Accident policy provided by Zurich American Insurance Company and authorize the
deduction from my earnings, if applicable, the required contribution toward the cost of the insurance. Coverage is available only for active, full-time Owner-
Operators (no operating authority or primary commercial automobile liability) and their Contract Drivers who: (1) work a minimum of 30 hours per week; (2)
are under a long-term lease agreement of 30 days or more, or who have entered into a contract of 30 days or more to provide Occupational services to an
Owner-Operator; and (3) have paid the required premium.
In enrolling for this insurance coverage, I hereby agree that I meet the eligibility requirements of this policy, and that I am not an employee of any company
for whom I perform services. I understand that if I have given any inaccurate, false or misleading information on this enrollment form, I will not be accepted
for coverage. I accept the insurance provided by the Group Accident policy and understand that at age 65, certain benefits may be reduced or eliminated. I
understand that coverage will begin no earlier than the date upon which the Company receives a fully completed and signed enrollment form and the required
premium has been paid.
This policy is NOT Workers’ Compensation and does not satisfy the Workers’ Compensation requirements that may be imposed upon or available to me.
Should I be or become eligible for Workers’ Compensation insurance, I will not be paid any amounts under this insurance. The benefits under this policy do
not necessarily equal the benefits that a Person might be eligible for under Workers’ Compensation.
The information below is only a brief description of the coverage provided under this group program. Refer to the Certificate of Insurance attached to the
Memorandum of Insurance for a description of benefits, limitations and exclusions.
OCCUPATIONAL ACCIDENT BENEFITS PLAN C NON-OCCUPATIONAL ACCIDENT BENEFITS PLAN C
ACCIDENTAL DEATH BENEFIT ACCIDENTAL DEATH BENEFIT
Principal Sum (Lump Sum Portion)* $50,000. Principal Sum* $10,000.
Accident Commencement Period 365 days Accident Commencement Period 365 days
SURVIVOR’S BENEFIT ACCIDENTAL DISMEMBERMENT BENEFIT
Principal Sum* $450,000. Principal Sum* $10,000.
Monthly Benefit Percentage 1% Accident Commencement Period 365 days
Monthly Benefit Amount $4,500.
ACCIDENTAL DISMEMBERMENT BENEFIT ACCIDENT MEDICAL & DENTAL EXPENSE BENEFIT
Principal Sum* $150,000. Medical Commencement Period 90 days
Accident Commencement Period 365 days Medical Deductible Amount $ 0.
Maximum Benefit Period 52 weeks
PARALYSIS BENEFIT Dental Maximum per Accident $1,000.
Principal Sum* $150,000. Maximum Benefit Amount per Accident $2,500.
Accident Commencement Period 365 days Lifetime Maximum Benefit $2,500.
TEMPORARY TOTAL DISABILITY BENEFIT
LIMITS ON MEDICAL BENEFITS
Disability Commencement Period 90 days
Physical Therapy, Occupational Therapy,
Waiting Period 7 days
Work Hardening Therapy Combined 36 visits
Benefit Percentage 66 2/3%
Ambulance (one round trip to and from
Minimum Weekly Benefit Amount $125.
a hospital for any one accident $1,000.
Maximum Weekly Benefit Amount $479.
Chiropractic Care per injury $1,000.
Maximum Benefit Period** 104 weeks
Hernia Coverage $ 0.
CONTINUOUS TOTAL DISABILITY BENEFIT*** Mental and Nervous
Waiting Period 104 weeks Outpatient: Maximum 20 visits any
Benefit Percentage 66 2/3% one accident $25. per visit
Minimum Weekly Benefit Amount $50. Inpatient: Maximum 20 days any
Maximum Weekly Benefit Amount $479. one accident $1,000.
Maximum Benefit Amount $200,000. Cumulative Trauma $ 0.
Maximum Benefit Period to age 70
LIMITS OF LIABILITY PLAN C
ACCIDENT MEDICAL & DENTAL EXPENSE BENEFIT
Medical Commencement Period 90 days Combined Single Limit $10,000.
Maximum Benefit Period 104 weeks Aggregate Limit of Liability $20,000.
Deductible Amount $0. (Applicable to all Covered Losses with
Dental Maximum per Accident $1,000. respect to any one Non-Occupational
Maximum Benefit Amount per Accident $1,000,000. Accident.)
Lifetime Maximum Benefit $1,000,000. _______________________________________________________
LIMITS ON MEDICAL BENEFITS
Physical Therapy, Occupational Therapy, * Age age 65, the Insured Person’s Principal Sum shall be based on
Work Hardening Therapy Combined 36 visits the following schedule:
Ambulance (one round trip to and from Age at Date of Loss 65 Percent of Principal Sum 80%
a hospital for any one accident $1,000. 66 60%
Chiropractic Care per injury $1,000. 67 40%
Hernia Coverage $ 0. 68 20%
Mental and Nervous $25. per visit 69 15%
Maximum 20 visits any one accident 70 and over 10%
Cumulative Trauma $ 0.
LIMITS OF LIABILITY ** If an Insured Person has an Injury at or after age 70, the
Combined Single Limit $1,000,000. Maximum Benefit Period shall be one (1) year.
Aggregate Limit of Liability $2,000,000.
(Applicable to all Covered Losses with *** If an Insured Person has an Injury after age 64 ½ or six months
respect to any one Occupational prior to the normal Social Security retirement age, the Insured
Accident.) Person cannot qualify for Continuous Total Disability.
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