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The Occupational Accident Programs offered by Ameriplan Benefit Corporation are provided by two "A" rated insurance companies with proven expertise in working with the trucking industry. We have collaborated with these companies and developed this Request For Proposal in order to properly underwrite the program.

Please answer the questions listed below as completely as possible and submit the form to us for quotation by clicking the button located at the bottom of the form.

Please do not hesitate to contact Bill Steben or Bud Sherrod if you have any questions about our Occupational Accident Programs or this Request For
Proposal. Our local number in Knoxville, Tennessee is 865-584-3655 and our toll free number is 1-800-228-1916.

REQUEST YOUR PERSONALIZED QUOTE

I. Company Profile
*Company Name:
*Address:
*City, State, Zip: State Zip
*Telephone:

(area-code) Number
Fax: (area-code) Number
*Your Email Address:
Years in Business :
USDOT #:
USDOT Rating:

 

II. Terminals and/or Locations

City

 State Description of Location

 

General Operation Questions:
1). Is there Occupational Accident coverage in force?

(If yes, please supply copy of schedule or certificate.)

 Yes
No
2).  If yes to #1, please list current insurer and current rate. Current Insurer:
Current Rate:
3). Does the motor carrier have Workers’ Compensation in force?

(If yes, please supply copy of DEC page and schedule)		 Yes
No
4). Number of current owner operators and contract drivers:

(Please provide driver list with DOB and contract date)

  
5). Are guest passengers or helpers allowed? Yes
No
6). What is the average annual miles per driver?
7). What type of trailer is used to haul commodities? Van/Box: %
Flatbed: %
Tanker: %
Container: %
Dump: %
Other: %
8). What commodities are hauled?
9). Do drivers load and unload? Yes
No

(If Yes, list percentage of time.)

%
10). Do drivers sign lease agreements?

(If yes, please provide a copy of standard agreement).

 Yes
No
11). Do you lease contract drivers from small fleets? Yes
No
(If yes, how many?)
Are they paid via 1099’s? Yes
No
12). Are the owner operators responsible for the maintenance of their trucks? Yes
No
13). How are the owner operators and contract drivers compensated?
14). What is the turnover percentage for owner operators? Current calendar year: %
Prior calendar year: %
15). Will the owner operators be required to have either Occupational Accident or
Workers' Compensation coverage?		 Yes
No
16). Will the motor carrier settlement deduct the Occ. Accident premiums?

(If yes, please include copy of sample settlement)

 Yes
No

 

III. Safety & Loss Control
1.) Name of Safety Manager:
2.) Number of years with company:
3.) Number of years in loss prevention:
4.) Please briefly describe ongoing safety program:
5.) Provide details of minimum standards for owner operators:

Minimum Age:

Maximum Age:

Minimum prior driving experience required:

Minimum prior experience driving similar equipment:

Maximum # of accidents permitted:

 in past years

Maximum # of violations permitted:

  in past years

What other criteria is used to qualify owner operators?

 

IV. Claims Experience

Provide three (3) years of Occupational Accident or Workers’ Compensation loss Runs. The losses should show paid claim amounts and reserves for AD&D, Medical and Disability. For any loss of $25,000 or more, please provide a brief narrative regarding the accident and the nature of the injury.

 

V. State Of Residence
Identify the number of owner/operator drivers by the state of residence:
Alabama Mississippi
Alaska Missouri
Arizona Montana
Arkansas Nebraska
California Nevada
Colorado New Hampshire
Connecticut New Jersey
Delaware New Mexico
District of Columbia New York
Florida North Carolina
Georgia North Dakota
Hawaii Ohio
Idaho Oklahoma
Illinois Oregon
Indiana Pennsylvania
Iowa Puerto Rico
Kansas Rhode Island
Kentucky South Carolina
Louisiana

South Dakota
Maine

Tennessee
Maryland

Texas
Massachusetts

Utah
Michigan

Vermont
Minnesota

Virginia

Washington
   

West Virginia
   

Wisconsin
   

Wyoming
   

 

  
   

TOTAL:

 

VI. Contingent Liability
1.) Please indicate whether or not Contingent Liability coverage is desired. Yes
No
2.) Have you ever experienced a loss under Workers' Compensation, contingent liability or similar coverage where an owner-operator or contract driver has been deemed an employee? Yes
No
If Yes (to question #2 above), please give details of each loss:
Date Description Amount Of Loss

VII: Plan Design To Be Quoted:

OCCUPATIONAL ACCIDENT BENEFITS

Accidental Death Benefit

*  Principal Sum....................................................................................... $   

    Accident Commencement Period............................................................ 365 days

 

Survivor’s Benefit:

*  Principal Sum......................................................................................... $

    Monthly Benefit Amount............................................................................ $1,000

 

Accidental Dismemberment Benefit:

*  Principal Sum....................................................................................... $

    Accident Commencement Period............................................................ 365 days

 

Paralysis Benefit:

*  Principal Sum....................................................................................... $

    Accident Commencement Period............................................................ 365 days

 

Temporary Total Disability Benefit:

     Disability Commencement Period............................................................. 90 days

     Waiting Period........................................................................................... 7 days

     Benefit Percentage........................................................................................ %

     Minimum Weekly Benefit Amount................................................................ $125

     Maximum Weekly Benefit Amount............................................................... $

** Maximum Benefit Period..................................................................... 104 weeks

 

***Continuous Total Disability Benefit:

      Waiting Period................ Maximum Benefit Period for Temporary Total Disability

      Benefit Percentage...................................................................................... %

      Minimum Weekly Benefit Amount................................................................. $50

      Maximum Weekly Benefit Amount.............................................................. $

      Maximum Benefit Amount................................................................... $

      Maximum Benefit Period...................................................................... to age 70

 

Accident Medical Expense Benefit:

    Medical Commencement Period............................................................... 90 days

    Deductible Amount........................................................................................... $0

    Maximum Benefit Period...................................................................... 104 weeks

    Dental Maximum................................................................... $1,000 per Accident

    Maximum Benefit Amount per Accident............................................ $

    Lifetime Maximum Benefit................................................................. $

 

LIMITS ON MEDICAL BENEFITS:

    Physical Therapy, Occupational Therapy, Work Hardening Therapy combined 36 visits

    Ambulance............ one round trip to and from a Hospital but not more than $1,000

    ............................................................................................. for any one Accident

    Chiropractic Care...................................................................... $1,000 per Injury

    Lifetime Maximum Benefit Period.............................................................. 90 days

    Mental and Nervous..... $25.00 per visit – maximum 20 visits for any one Accident

    Cumulative Trauma, Occupational Disease, Hernia……………$

 

LIMITS OF LIABILITY

   Combined Single Limit....................................................................... $

   Aggregate Limit of Liability................................................................ $

    (applicable to all Covered Losses with respect to any one Occupational Accident)

 

*At age 65, the Insured Person’s Principal Sum shall be based on the following Schedule:

 

Age at Date of Loss

Percent of Principal Sum

65

80%

66

60%

67

40%

68

20%

69

15%

70 and over

10%

**If an Insured Person has an Injury at or after age 70, the Maximum Benefit Period shall be one (1) year.

 

***If an Insured Person has an Injury after age 64½ or six months prior to the normal Social Security retirement age, the Insured Person cannot qualify for Continuous Total Disability.

 

NON-OCCUPATIONAL ACCIDENT BENEFITS

Accidental Death Benefit:

*   Principal Sum........................................................................................ $

     Accident Commencement Period........................................................... 365 days

 

Accidental Dismemberment Benefit:

*   Principal Sum ....................................................................................... $

     Accident Commencement Period........................................................... 365 days

 

Accident Medical Expense Benefit:

    Medical Commencement Period............................................................... 90 days

    Deductible Amount........................................................................................... $0

    Maximum Benefit Period........................................................................ 52 weeks

    Dental Maximum................................................................... $1,000 per Accident

    Maximum Benefit Amount per Accident.................................................... $

    Lifetime Maximum Benefit......................................................................... $

 

 

LIMITS ON MEDICAL BENEFITS:

    Physical Therapy, Occupational Therapy, Work Hardening Therapy combined 36 visits

    Ambulance............ one round trip to and from a Hospital but not more than $1,000

................................................................................................. for any one Accident

  Chiropractic Care........................................................................ $1,000 per Injury

   Lifetime Maximum Benefit Period............................................................... 90 days

  Mental and Nervous Outpatient: $25.00 per visit – max. 20 visits for any one Accident

         Inpatient: Maximum 20 visits – maximum $1,000 for any one Accident

   Cumulative Trauma............................................................................................ $0

 

LIMITS OF LIABILITY

 Combined Single Limit............................................................................... $

 Aggregate Limit of Liability........................................................................ $

 (applicable to all Covered Losses with respect to any one Non-Occupational Accident)

 

By submitting this completed form you understand that there is no coverage in force until an application is approved and premium is received by the insurance company.  You certify that the statements made on this quote request are accurate to the best of your knowledge.  This Web site should not be construed as a solicitation of any sort in any jurisdictions other than those in which the agency holds a license and is authorized to transact business.

PLEASE CLICK THE FOLLOWING SUBMISSION BUTTON
TO SEND US YOUR COMPLETED REQUEST

 

 
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