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) 6 of 6 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) 1 of 6 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) 2 of 6 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 3 of 6 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) 4 of 6 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) 5 of 6
