TXN INTERMODAL, INC. Occupational Accident FAQs

Transcription

1 TXN INTERMODAL, INC Occupational Accident FAQs WHAT IS OCCUPATIONAL ACCIDENT INSURANCE? Occupational Accident (Occ/Acc) is an affordable alternative to statutory Workers Compensation Insurance. Occ/Acc is an insurance product designed for Independent Contractors to provide coverage for medical expenses, loss of wages, and provide benefits resulting from a loss due to a work related accident or injury. WHAT TYPE OF COVERAGE DOES OCCUPATIONAL ACCIDENT INSURANCE PROVIDE? There are three components of Occ/Acc: 1. Accidental Death and Dismemberment: A benefit paid monthly to the owner-operator or their beneficiaries in the event of the loss of use of certain body parts or their death. One Beacon pays up to $250, Medical: When a driver is involved in an accident requiring medical treatment the medical expense coverage will pay for the medical costs up to the limits of the policy for two years. One Beacon pays Combined Single Limit of $1,000,000 Medical treatment must commence within 90 days of date of accident causing the covered injury. 3. Disability (70% of Average Weekly Wage subject to Maximum of $500) Temporary Total Disability: Partial wage replacement benefit paid to the owner-operator in the event of a covered injury resulting in an inability for the owner-operator to work during the time they are recovering from the covered injury. The disability must commence within 90 days from date of accident causing the injury Maximum Benefit Period 104 weeks, or age 70. Continuous Total Disability (after Temporary Total Disability Period of 104 weeks): Partial wage replacement benefit paid to the owner-operator in the event of an injury resulting in the complete inability for the owner-operator to work in their qualified occupation during the time they are recovering from the injury. Maximum Benefit Period up to age 70 (injury must occur prior to age 65). Insured must qualify for Social Security Disability Award to be eligible for CTD. If an Insured Person sustains a Covered Injury after the Insured Person s normal Social Security retirement age, as determined by federal law, the Insured Person cannot qualify for Continuous Total Disability.

2 HOW ARE MY TEMPORARY TOTAL DISABILITY PAYMENTS CALCULATED? For Class I Owner-Operators: Thirty-three percent (33%) of the gross income the Insured Person received in the prior year as shown in his or her federal income tax return with schedules or 1099s, divided by 52, regardless of his or her prior occupation. If the Insured Person worked less than fifty (50) weeks during the prior year, then thirty-three percent (33%) of the gross income received in the prior year as shown in his or her federal income tax return with schedules or 1099s, divided by the number of weeks worked, regardless of his or her prior occupation. The Insured Person will have to produce proof, which is satisfactory to us, of the number of weeks worked if he or she is claiming less than fifty (50) weeks. For Class II Contract Drivers: Seventy-five percent (75%) of the gross income the Insured Person received in the prior year as shown in his or her federal income tax return with schedules or 1099s or similar wage reporting documents divided by 52 regardless of his or her prior occupation. If the Insured Person worked less than fifty (50) weeks during the prior year, then seventy-five percent (75%) of the gross income received in the prior year as shown in his or her federal income tax return with schedules or 1099s or similar wage reporting documents divided by the number of weeks worked, regardless of his or her prior occupation. The Insured Person will have to produce proof, which is satisfactory to Us, of the number of weeks worked, if he or she is claiming less than fifty (50) weeks. IS THE MEDICAL PORTION OF MY OCCUPATIONAL ACCIDENT INSURANCE PRIMARY OR SECONDARY WITH ONE BEACON? The coverage is secondary ONLY if you have a Medical Insurance Policy that will cover workrelated injuries. Most Medical Insurance Policies do not cover work-related injuries. If your Medical Insurance Policy will cover work-related injuries your Occupational Accident Policy will cover any out-of pocket expenses you incur such as co-pays and deductibles or treatments that are necessary. If you have Medical Insurance check with your company to determine if your policy covers workrelated injuries.

3 TXN Intermodal, Inc Owner-Operator Occ/Acc Coverage Overview IX. Benefits: Note: These benefits are subject to the terms, conditions, limitations and exclusions as stated in the Policy and in Section XIII of this Application. A. Occupational Accident Benefits: Accidental Death Benefit: Principal Sum*... $50,000 Accident Commencement Period days Survivor's Benefit: Principal Sum*... up to $200,000 Monthly Benefit Percentage... 1% Monthly Benefit Amount... $2000 Accidental Dismemberment Benefit: Principal Sum *... up to $250,000 Paralysis Benefit: Principal Sum *... up to $250,000 Temporary Total Disability Benefit: Disability Commencement Period days Waiting Period... 7 days Benefit Percentage... 70% of AWE Minimum Weekly Benefit Amount... $125 Maximum Weekly Benefit Amount... $500 Maximum Benefit Period ** weeks Maximum Benefit Period for Hernia weeks Continuous Total Disability Benefit: *** Waiting Period... Maximum Benefit Period for Temporary Total Disability Benefit Percentage... 70% of AWE Minimum Weekly Benefit Amount... $50 Maximum Weekly Benefit Amount... $500 Maximum Benefit Amount... $400,000 Maximum Benefit Period... to age 70 Accident Medical Expense Benefit: Medical Commencement Period days Deductible Amount... $0 Maximum Benefit Period weeks Dental Maximum... $3,600 per Accident Maximum Benefit Amount per Accident... $1,000,000 Lifetime Maximum Benefit... $1,000,000 Limits on Accident Medical Expense Benefits: Services provided by a Chiropractor or Acupuncturist, not including Physical Therapy, Occupational Therapy, Work Hardening Therapy... $1,000 per Injury Ambulance... one round trip to and from a hospital but not more than $1,000 for any one Accident Air Ambulance... one round trip to and from a Hospital but not more than $7,000 for any one Accident

4 Hernia Coverage... lifetime Maximum Benefit of $10,000 Mental and Nervous Outpatient... $25 per visit maximum maximum 20 visits for any one Accident Mental and Nervous Inpatient... maximum 20 days maximum maximum $1,000 for any one Accident * The Accidental Dismemberment Benefit and the Paralysis Benefit will be paid as a Monthly Benefit at 1% of the applicable Principal Sum. The payment of this Monthly Benefit will cease upon the earliest of the following: (1) the date the total of the applicable Principal Sum has been paid; or (2) the date the Insured Person dies. The most OneBeacon will pay for these benefits, as well as the Accidental Death Benefit, in total, is the Insured Person s Principal Sum, if the Insured Person can recover benefits under more than one of the benefits as a result of the same Accident. At age 65, the Insured Person's Principal Sum will be based on the following schedule: Payment For Death and Survivor Benefits, Age at Date of Loss For Dismemberment and Paralysis Benefits, Age at Date of Benefit % of Principal Sum 65 80% 66 60% 67 40% 68 20% 69 15% 70 and over 10% ** If an Insured Person sustains a Covered Injury at or after age 70, the Maximum Benefit Period will be one (1) year. *** If an Insured Person sustains a Covered Injury after the Insured Person s normal Social Security retirement age, as determined by federal law, the Insured Person cannot qualify for Continuous Total Disability. For purposes of the Temporary Total Disability and the Continuous Total Disability Benefits, Average Weekly Earnings (AWE) will be calculated as follows: For Class I Owner-Operators: Thirty-three percent (33%) of the gross income the Insured Person received in the prior year as shown in his or her federal income tax return with schedules or 1099s, divided by 52, regardless of his or her prior occupation. If the Insured Person worked less than fifty (50) weeks during the prior year, then thirty-three percent (33%) of the gross income received in the prior year as shown in his or her federal income tax return with schedules or 1099s, divided by the number of weeks worked, regardless of his or her prior occupation. The Insured Person will have to produce proof, which is satisfactory to us, of the number of weeks worked if he or she is claiming less than fifty (50) weeks. For Class II Contract Drivers: Seventy-five percent (75%) of the gross income the Insured Person received in the prior year as shown in his or her federal income tax return with schedules or 1099s or similar wage reporting documents divided by 52 regardless of his or her prior occupation. If the Insured Person worked less than fifty (50) weeks during the prior year, then seventy-five percent (75%) of the gross income received in the prior year as shown in his or her federal income tax return with schedules or 1099s or similar wage reporting documents divided by the number of weeks worked, regardless of his or her prior occupation. The Insured Person will have to produce proof, which is satisfactory to Us, of the number of weeks worked, if he or she is claiming less than fifty (50) weeks.

5 B. Non-Occupational Accident Benefits Accidental Death Benefit: Principal Sum *... $10,000 Accidental Dismemberment Benefit: Principal Sum *... up to $10,000 Accident Medical Expense Benefit: Medical Commencement Period days Deductible Amount... $0 Maximum Benefit Period weeks Dental Maximum... $1,000 per Accident Maximum Benefit Amount per Accident... $5,000 Lifetime Maximum Benefit... $10,000 Limits on Accident Medical Expense Benefits: Physical Therapy, Occupational Therapy, Work Hardening Therapy... $1,000 per Injury Services provided by a Chiropractor or Acupuncturist, not including Physical Therapy, Occupational Therapy, Work Hardening Therapy... $1,000 per Injury Ambulance... one round trip to and from a Hospital but not more than $1,000 for any one Accident Air Ambulance... one round trip to and from a Hospital but not more than $7,000 for any one Accident Mental and Nervous - Outpatient... $25 per visit maximum 20 visits for any one Accident Mental and Nervous Inpatient... maximum 20 days maximum $1,000 for any one Accident * The Accidental Dismemberment Benefit will be paid as a Monthly Benefit at 1% of the applicable Principal Sum. The payment of this Monthly Benefit will cease upon the earliest of the following: (1) the date the total of the applicable Principal Sum has been paid; or (2) the date the Insured Person dies. The most OneBeacon will pay for these benefits, as well as the Accidental Death Benefit, in total, is the Insured Person s Principal Sum, if the Insured Person can recover benefits under more than one of the benefits as a result of the same Accident. At age 65, the Insured Person's Principal Sum will be based on the following schedule: For Death Benefit, Age at Date of Loss For Dismemberment Benefit, Age at Date of Benefit Payment % of Principal Sum 65 80% 66 60% 67 40% 68 20% 69 15% 70 and over 10%

6 OneBeacon America Insurance Company Canton, Massachusetts DRIVER ENROLLMENT AND BENEFICIARY FORM TRUCKERS OCCUPATIONAL ACCIDENT INSURANCE TXN INTERMODAL, INC # 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: CDL Number: Number of Years Experience: Contracted by (Name of Company): Effective Date of Contract: Street Address: City: State: Zip: Motor Carrier Telephone Number: Fax Number: Motor Carrier E Mail Address: FRAUD STATEMENT Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and will also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. In providing this information, I, the undersigned, understand and hereby state that: 1. to the best of my knowledge and belief, all information on this Form is complete and truthful; 2. this coverage being is not a contract for Statutory Workers Compensation Insurance, and neither I nor my carrier become participants in the Workers Compensation system by purchasing this insurance; and 3. if, based on the information supplied in this Form, I am not eligible for coverage, premium will be refunded and no claims will be payable. By my signature below, I, the undersigned, also 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 OneBeacon America Insurance Company, the motor carrier or the motor carrier s designee. A photographic copy of this authorization shall be as valid as the original. IF THE INFORMATION PROVIDED IN THIS FORM IS FRAUDULENT, THE INSURER HAS THE RIGHT TO RETURN PREMIUM AND CANCEL COVERAGE. In order to verify the information provided in this Form, I, the undersigned, give the Insurer authority to examine the records that are maintained by the motor carrier. I certify that I am an independent contractor, paid by a 1099 tax form, not as a W 2 employee. Driver s Signature: Date: Motor Carrier Representative s Signature: Payment Authorization: I authorize the above named motor carrier, 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 OneBeacon America Insurance Company. I UNDERSTAND THAT THE COST OF THE INSURANCE IS MY SOLE OBLIGATION AND RESPONSIBILITY, regardless of the above arrangement of premium payment. I agree that I will forward any amount due and owing to OneBeacon America Insurance Company, upon demand, for any insurance at any time my account remains unpaid. Signature: Date: