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TRUCKERS OCCUPATIONAL ACCIDENT INSURANCE
SUMMARY of BENEFITS and ENROLLMENT FORM
For NorthAmerican Transportation Association, Inc.
Benefits |
Plan A |
Plan B |
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Accidental Death BenefitsLump Sum Survivors Benefit
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$50,000 $150,000 $1,500 Month for 100 mo |
$25,000 $125,000 $1,000 Month for 125 mo |
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Accidental DismembermentPeriod For Loss of: Life Both Hands or Feet or Sight of Both Eyes One Hand and One Foot One Hand or Foot and One Eye One Hand, One Foot or One Eye Thumb & Index Finger |
$200,000 365 Days
100% 100% 100% 100% 50% 25% |
$150,000 365 Days
100% 100% 100% 100% 50% 25% |
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Temporary DisabilityCommencement Period Waiting Period Participation Percentage Maximum Weekly Benefit Maximum Benefit Period |
30 Days 7 Days 66 2/3 % $450 104 Weeks |
30 Days 14 Days 66 2/3 % $450 52 Weeks |
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Continuous Total DisabilityParticipation Percentage Maximum Weekly Benefit Maximum Benefit Period |
66 2/3 % $450 To Age 65 |
66 2/3 % $450 5 Years |
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Accidental Medical ExpenseCommencement Period Deductible Amount Incurral Period Dental Benefit
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$1,000,000 30 Days $100 2 Years $1,000 $125 per tooth |
$500,000 30 Days $150 1 Year $1,000 $100 per tooth |
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Non-Occupational CoverageAccidental Death & Dismemberment Accident Medical Deductible |
$10,000 $5,000 0 |
$10,000 $5,000 0 |
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Combined Single Limit |
$1,000,000 |
$500,000 |
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Aggregate per Occurrence |
$2,000,000 |
$1,000,000 |
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Association Administration Fee |
$5.00 |
$5.00 |
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Premium Rates - Monthly per person |
$129.00 |
$99.00 |
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Total Premium |
$134.00 |
$104.00 |
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IMPORTANT INFORMATION: This is only a brief description of coverage. For complete details, please refer to your certificate of insurance. The underwriting company is AIG Life Insurance Company. In the event of any conflict between this form and the actual master policy, the master policy will govern in all cases. BENEFIT ELECTION: I hereby accept the insurance provided by the group insurance plan and authorize the deduction from my earnings of the required contribution toward the cost of the insurance. I understand that I upon my 65th birthday and that coverage will therefore cease. I understand that coverage will begin on the first day of the month following my completing and signing this enrollment form and the required premium has been paid. I elect the following coverage: Circle one Plan A Plan B |
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Print Name Here |
Signature |
Effective Date |
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