Occupational Accident Insurance Form

OCCUPATIONAL ACCIDENT INSURANCE FORM

Applicant / Insured Information

Policy Details Requested / Existing Policy

Policy Type Requested: Occupational Accident Weekly Indemnity Medical Only Catastrophic Loss

Policy Period From to . Requested Effective Date:

Coverage Selections and Limits

Select coverages and indicate limits where applicable:

Include medical expense coverage up to per accident (reasonable and customary).

Weekly benefit of subject to a maximum of weeks after Waiting Period of days.

Principal sum for accidental death/dismemberment:

Include vocational rehabilitation up to .

Exclusions and Limitations

The insurance applied for will not cover losses caused by or resulting from: (a) intentional self-inflicted injury, suicide or attempted suicide while sane or insane; (b) injury sustained while committing or attempting to commit a felony or engaged in an illegal occupation; (c) injuries arising from active military service or declared war; (d) losses due to intoxication where blood alcohol or toxicology establishes impairment beyond legal limits; (e) pre-existing conditions excluded as stated in the policy declarations; (f) injuries covered by workers' compensation where exclusive remedy applies except as otherwise provided in the policy; (g) elective cosmetic procedures except those required to repair accidental injury.

Benefits are subject to policy definitions, limits, waiting periods, subrogation and coordination of benefits provisions set forth in the issued policy. Any coverage provided is conditional upon timely payment of premium and accurate disclosure of material facts.

Beneficiary Designation

Designate one or more primary beneficiaries for Accidental Death benefits. Percentages must total 100%.

Prior Claims and Medical History

Have you suffered an occupational accident, filed an occupational accident claim, or received disability payments in the last 5 years? Yes No

Do you currently have any physical or medical condition that could increase the risk of accidental injury? Yes No

Claim Notification & Documentation Checklist

In the event of an occupational accident, the insured or employer must provide notice as soon as reasonably possible. The following documentation is typically required to process a claim:

Employer incident/accident report
Medical records and itemized bills
Pay records and employment verification
Photos of injury or accident scene (if available)

Subrogation, Coordination of Benefits and Fraud Warning

By signing this application, the applicant authorizes the insurer to exercise subrogation and recovery rights against any party legally responsible for payment of benefits. Benefits payable under any policy are subject to reduction where the insured is entitled to recover from third parties, and the insurer may pursue reimbursement to the extent of benefits paid. Coordination of benefits applies where other valid and collectible insurance exists; the policy will articulate the order of benefit determination.

It is a crime to knowingly provide false, incomplete, or misleading information for the purpose of defrauding the insurer. Any person who knowingly presents false information may be subject to civil and criminal penalties under applicable law and denial of coverage.

Authorization and Consent to Release Information

The applicant authorizes any licensed physician, medical professional, hospital, clinic, employer or insurer to release to the insurer any medical or employment records necessary to adjudicate claims under the policy. This authorization extends to the exchange of protected health information for underwriting, claim investigation, payment and fraud prevention purposes. A photocopy or electronic reproduction of this authorization shall be as valid as the original.

Declaration and Applicant Certification

I hereby apply for the insurance indicated on this form. I certify that the statements and answers provided on this form are true, complete and correctly recorded to the best of my knowledge. I understand that coverage, if issued, will be subject to all terms, conditions, limitations and exclusions contained in the policy. I acknowledge that the insurer may rescind or deny coverage if material misrepresentations or omissions are discovered.

I authorize the insurer to obtain and verify information necessary for underwriting and claims administration and understand that a consumer or investigative report may be requested where permitted by law. I consent to electronic delivery of policy documents where permitted.

By signing below I acknowledge receipt of and agreement to these terms and certify under penalty of perjury that the information provided in this application is true and correct.

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