Occupational Accident Insurance Policy Group Master Application (the Application )

Transcription

1 Occupational Accident Insurance Policy Group Master Application (the Application ) APPLICANT INFORMATION Legal Name ( Employer ) Address Contact Person Phone Number Fax# Nature of Business Federal Tax ID Number Are any affiliated organizations to be covered? No Yes (please provide on separate sheet) INSURANCE COVERAGES REQUESTED Requested Effective : Plan Type: Pay on Behalf Combined Single Limit (per Insured/Occurrence): Aggregate Limit per Occurrence: Annual Policy Aggregate Limit: Accidental Death and Dismemberment lesser of 10x Base Annual Earnings or Deductible (per Insured/Occurrence): Disability Benefit: Medical/Disability Benefit Period Percent of Average Weekly Earnings Weekly Income Maximum Elimination Period: Weeks % Days Is Employer s Indemnity Coverage Requested? Yes No Is Waiver of Subrogation Requested? Yes No Is Occupational Disease & Cumulative Trauma Coverage Requested? Yes No Is Pilot Crew Members Coverage Requested? Yes No Plan Benefits: All benefits listed above are subject to the Combined Single Limit. Attached: Census or TWC report NONSUBSCRIBER NOTICE This is not a policy of worker s compensation insurance. The Employer does not become a subscriber to the worker s compensation system by purchasing the policy, and if the Employer is a non-subscriber, the Employer loses those benefits which would otherwise accrue under the worker s compensation laws. By signing this application you warrant that you will comply with the worker s compensation law as it pertains to nonsubscribers and that the required notices will be filed and posted. OCCACC-11-APP-P Page 1 of 2

2 APPLICANT STATEMENT By signing this application, I understand, acknowledge and agree on behalf of the Applicant: I have made an application to Pan-American Life Insurance Company for an Occupational Accident Insurance Policy and no insurance coverage is afforded until this application is accepted in writing by Pan-American Life Insurance Company, all information (including all attachments) in the Application is true and complete, I have reviewed and understand the coverage s, limits, terms, and exclusions of the insurance policy, the insurance coverage applied for indemnifies or reimburses for Employee Occupational Injury Plan Benefits only to the extent provided in the Employee Occupational Injury Plan and does not insure any casualty or general liability risk of the Applicant, the coverage applied for does not indemnify or reimburse the Applicant for an losses, damages or awards to employees from a finding of negligence or otherwise for accidental injury or death unless the Applicant specifically applies for the Amendment or Employer Indemnity Coverage, the application will become a part of the insurance policy and as such contains accurate representations as to the risk to be insured, that insurance coverage is also conditioned upon the requirements as set forth in the pricing indication given in response to this Application and any such indication is not an offer to effect coverage, the insurance coverage applied for is not a policy of Worker s Compensation insurance nor is it a replacement for Worker s Compensation insurance, and I have read and understand the NONSUBSCRIBER NOTICE immediately above, certain conditions or disabilities that may be work related and compensable, according to the Texas Worker s Compensation statutes, are not covered nor intended to be covered under this insurance policy, and WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OT ANY OTHER PERSON. PENALTIES INCLUDED IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS OT FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT Employer Name Authorized Signature of Applicant Agent s Signature OCCACC-11-APP-P Page 2 of 2

3 Disclosure and Acknowledgment Concerning Workers Compensation This will acknowledge that in solicitation of my business insurance, the Agent named below (herein referred to as Agent ), explained to me the following facts about the Texas Workers Compensation Act (the Act ). The following facts were discussed, and as an employer I am aware of their importance. To my knowledge, no statements contrary to the following statements were made by the Agent to anyone employed by, or representing, the Named Insured. 1. Workers Compensation Insurance is a No-Fault system that affords coverage for my employees and protections for me which no alternative insurance plan can duplicate. 2. It is my responsibility, should I elect not to purchase workers compensation insurance, to notify the Texas Department of Insurance, Division of Workers Compensation ( DWC ) at the time of such election by filing the appropriate form (currently the DWC Form 5). I must also annually file the appropriate form (currently DWC Form 5) with the DWC on the anniversary date of the original filing or if I have canceled my workers compensation policy, on the anniversary of the cancellation date of the workers compensation policy. I am aware of the penalty for failure to properly file can be as much as $500 per day. I also must notify my workers compensation carrier, in the manner provided by the law, at the time of my election. All notices and elections must be made by certified mail, return receipt requested. 3. Agent has advised me that if I become a non-subscriber under the Act, I should seek the advice of competent legal counsel in meeting the provisions of the Act. Agent has advised me to seek legal advice for the current law as it applies to my situation. 4. I am aware that as a non-subscriber, should I purchase an alternative insurance product that provides Injury medical benefits for my employees, I come under the Employee Retirement Income Security Act of 1974 (ERISA). It is in my best interest to have a written employee injury benefit plan, and to file this plan under ERISA with the U.S. Department of Labor. Such insurance and plan do not preempt a personal injury negligence lawsuit. 5. I understand that an approved safety program could help reduce the frequency and severity of on-the-job injuries and could also help us meet our responsibility to provide a reasonably safe place to work for our employees. Agent has shown me an alternative work place Injury insurance plan. I acknowledge the option I have selected is solely my choice and the alternative plan I have chosen was not represented by Agent to any person as being a substitute for statutory workers compensation insurance. Agent did not induce me or any representative of my company to reject Workers Compensation. THIS IS NOT A POLICY OF WORKERS COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED. I read the above and acknowledge the Agent has discussed each of these items with me. Signed this day of, 20. Insured Officer/Owner Signature Name (please print) Agent Signature Firm Name (please print)

4 National Specialty Insurance Company Employer Indemnity Coverage Policy Group Master Application (the Application ) APPLICANT INFORMATION Legal Name ( Employer ) Address Contact Person Phone Number Fax# Nature of Business Federal Tax ID Number Are any affiliated organizations to be covered? No Yes (please provide on separate sheet) COVERED CLASSES: Class Description Location INSURANCE COVERAGES REQUESTED Requested Effective : Combined Single Limit (per Insured/Occurrence): Aggregate Limit per Occurrence: Policy Aggregate Limit (includes defense costs): Deductible (per Scheduled Employee per Occurrence): COVERED OCCURRENCES REQUESTED Occupational Disease Cumulative Trauma Yes No Yes No Plan Benefits: All benefits listed above are subject to the Combined Single Limit. EL-OCCACC-SN-APP-14 ED 8-14 Page 1 of 2

5 NONSUBSCRIBER NOTICE This is not a policy of worker s compensation insurance. The Employer does not become a subscriber to the worker s compensation system by purchasing the policy, and if the Employer is a non-subscriber, the Employer loses those benefits which would otherwise accrue under the worker s compensation laws. By signing this application you warrant that you will comply with the worker s compensation law as it pertains to nonsubscribers and that the required notices will be filed and posted. APPLICANT STATEMENT By signing this application, I understand, acknowledge and agree on behalf of the Applicant: I have made an application to National Specialty Insurance Company for an Employer Indemnity Coverage Insurance Policy and no insurance coverage is afforded until this application is accepted in writing by National Specialty Insurance Company; all information (including all attachments) in the Application is true and complete, I have reviewed and understand the coverage s, limits, terms, and exclusions of the insurance policy, the application will become a part of the insurance policy and as such contains accurate representations as to the risk to be insured, that insurance coverage is also conditioned upon the requirements as set forth in the pricing indication given in response to this Application and any such indication is not an offer to effect coverage, the insurance coverage applied for is not a policy of Worker s Compensation insurance nor is it a replacement for Worker s Compensation insurance, and I have read and understand the NONSUBSCRIBER NOTICE immediately above, certain conditions or disabilities that may be work related and compensable, according to the Texas Worker s Compensation statutes, are not covered nor intended to be covered under this insurance policy, and WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDED IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT Employer Name Authorized Signature of Applicant Agent s Signature EL-OCCACC-SN-APP-14 ED 8-14 Page 2 of 2