Truckers Occupational Accident Insurance Questionnaire Form Page 2
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415. Please attach separate sheets listing prior Workers’ Compensation or Occupational Accident Insurance currently valued
detailed loss information for the past five years. If no prior coverage, please provide a list of any deaths, dismemberments,
permanent total disabilities, or claims over $1,000 in the past five years.
16. Is this a voluntary program?
Yes
No If Yes, please explain how enrollment will be handled: ______________
__________________________________________________________________________________________________
17. BENEFIT PLAN DESIRED
Accidental Death & Dismemberment
Non-Occupational Accident Coverage
Accidental Death (Lump Sum): $ ____________________
Accidental Death:
$ ____________________
Survivors Benefit: $ _________ for ____________ Months
Accidental Dismemberment:
$ ____________________
Accidental Dismemberment:
$ _____________________
Accident Medical Expense
Lump Sum
or
Monthly Benefit: ___ Months
Benefit Amount:
$ _____________________
Paralysis
Benefit Period:
______________ Week(s)
Principal Sum:
$ _____________________
Deductible Amount:
$ _____________________
Benefits are on the same basis (primary or excess) as for
Lump Sum or
occupational accident coverage.
Monthly Benefit: ___ Months
Accident Medical Expense
Passenger Accident Coverage
Benefit Amount:
$____________________
Accidental Death:
$____________________
Benefit Period:
______________ Week(s)
Accidental Dismemberment:
$____________________
Deductible Amount:
$ _____________________
Lump Sum
Monthly Benefit: ____ Months
or
Benefits Are (choose one):
Primary or
Excess
Paralysis Principal Sum:
$____________________
Temporary Total Disability (TTD)
Lump Sum
or
Monthly Benefit: ____ Months
Benefit Amount:
$ _____________________
Accident Medical Expense
Waiting Period:
__________________ Day(s)
Benefit Amount:
$ _____________________
Benefit Period:
_________________ Week(s)
Benefit Period:
_________________ Week(s)
Deductible Amount:
$ _____________________
Participation Percentage:
_________________________%
Benefits are on the same basis (primary or excess) as for
Continuous Total Disability (CTD)
occupational accident coverage.
(Must be same Benefit Amount as TTD.)
Benefit Period:
_________________________
Any other benefits desired? (State benefits and limits.)
_____________________________________________________________
Combined Single Limit Option
_____________________________________________________________
Yes
No
Amount:
$ ___________________
_____________________________________________________________
$ ___________________
Aggregate Per Person:
_____________________________________________________________
$ ___________________
___________________________________________________
Aggregate Per Occurrence:
I hereby acknowledge that all answers and statements contained, including the attached data, are true and complete.
I also understand that no coverage will become effective until an application has been signed and approved by the
Insurance Company, a policy of Insurance is issued, and the required premium is paid. I also understand that these are
accident insurance coverages and are not in lieu of or in fulfillment of Workers’ Compensation insurance.
Broker/Agent Signature
Applicant Signature
Date: _________________________________________________
Date: ________________________________________________
Please tell us about your organization.
Producer Name: __________________________________ Producer Code: ___________________________________
(if known)
Contact Person: __________________________________________________________________________________
Street Address: __________________________________________________________________________________________
City: ___________________________________________ State: ____________ Zip Code: ___________________
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Telephone Number: ______________________________ Fax Number: ____________________________________
E-Mail Address: _________________________________ Web Address: ___________________________________
Requested Commission: ___________________________
Underwritten by AIG Life Insurance Company, Wilmington, DE, American International Life Assurance Company of New York, New York, NY, and
American Home Assurance Company, New York, NY (collectively referred to as the “Insurance Company”), members of American International Group, Inc.
Coverage is not available in all states. AIG Life does not solicit business in New York.
HCMB:OCC:1Q 01/00
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