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REQUEST FOR INSURANCE

 Plan A – Survivor Benefit $150,000

 Plan B – Survivor Benefit $125,000

AIG Life Insurance Co Master Policy TRK 9101311

For NorthAmerican Transportation Association, Inc.  

 

Name

 

Address

 

    City

 

State

 

Zip

 

Driver’s License

 

Social Security

 

Contracted to

Motor Carrier

 

Address

 

City

 

State

 

Zip

 

Telephone:

Commodities Hauled

Vehicle Registration Number

 

 

Beneficiary Name & Address

Relationship to Insured

Social Security Number

 

 

 

 

 

 

 

 

 

By signing this Request for Insurance, you, the person requesting insurance, agrees to all of the following that to be covered under the above specified group policy as a member:

1.     I am a active, full-time independent truck owner/operator and/or co-driver contracted with a motor carrier to haul commodities under a signed lease agreement,

2.     The required premium has been paid,

3.     I have personally signed this enrollment form and

4.     That all of the statements made in this request are, to the best of my knowledge and belief, true and accurate.

EXCLUSIONS:

  1. Suicide or any attempt thereof while sane or self destruction or any attempt thereat while insane;
  2. Infections, except phylogenic infections caused wholly by a covered injury;
  3. War or any act of war, or accident occurring while in the military, navel or air service of any country (any premium paid to the Company for any period not covered while you are in such service will be returned pro-rata);
  4. Accident occurring while you are operating or learning to operate or performing duties as a member of the crew of any aircraft;
  5. Dental treatment, except as a result of injury to sound natural teeth:
  6. Replacement of eyeglasses or eye examination for the correction of vision or fitting of glasses unless an injury has caused impairment of sight;
  7. Injury for which you are entitled to benefits under any Workers’ Compensation Act or Law or any similar legislation;
  8. Participating in team sports or other athletic activities;
  9. Hernia of any kind;
  10. Being intoxicated or under the influence of any narcotic unless on the advice of a physician
  11. Cumulative trauma, repetitive conditions or conditions for which you have sought or received medical advice or treatment twelve (12) months prior to becoming insured under this plan (including but not limited to coronary or circulatory conditions;
  12. Pain, suffering and/or loss of an emotional, psychological or psychiatric nature or
  13. Bodily injury by disease