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TRUCK DRIVERS

OCCUPATIONAL ACCIDENT PROGRAM OWNER-OPERATOR & W-2 EMPLOYEE

Transportation companies and their drivers make an important contribution to our national economy, yet face occupational risks that require protection in the event of an on-the-job accident. Combined Group Insurance Services is pleased to offer an occupational accident program specifically for truck drivers. The program, Comprehensive Truckers Protection (CTP), will be administered by Combined

Group Insurance Services. The Comprehensive Truckers Protection program is an occupational

accident insurance plan, which provides an effective and flexible method to obtain needed

protection. The insurance coverage will be provided by American Fidelity Assurance, an A+ (15)

A.M. Best rated carrier.

The Comprehensive Truckers Protection (CTP) program by Combined Group Insurance Services

offers coverages, subject to eligibility, for trucking firms with 1099 Owner-Operator drivers

and/or W-2 Employee drivers. CTP provides coverage for the following:

• Accidental Death and Dismemberment

• Accident Medical

• Weekly Accident Disability Income

You select the Deductible and Accidental Medical that best fits your needs and budget.

Coverage for occupational disease, cumulative trauma and occupational hernia is included,

subject to policy limits.

American Fidelity Assurance is rated A+ (Excellent) for financial strength by A.M. Best Company Inc.

In these budget challenging

times, smart Texas trucking

firms are signing up for CTP –

with different coverage

options to fit your budget.

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1099 OWNER-OPERATOR DRIVER

BLANKET GROUP OCCUPATIONAL ACCIDENT POLICY

COVERAGE INFORMATION

OCCUPATIONAL ACCIDENT COVERGE

Accident Medical Expense Coverage

• $1,000 or $2,500 deductible per person, per injury

• Pays up to the amount selected for covered medical expenses due to a covered accident when incurred within 104 weeks of the accident

• Pays usual, reasonable and customary charges for covered physicians’ fees, prescribed medical and/or surgical services and supplies, and hospital charges

• Benefits for ambulance services, manipulation therapy, and mental and nervous conditions are limited

• Pays for covered dental expenses

Weekly Accident Disability Income

• Pays a maximum of $600 per week for up to 104 weeks, not to exceed 75% of base salary

• Payable if driver is unable to perform the material and substantial duties of his own occupation due to a covered accident

• Payments begin after 5-day Elimination Waiting period

Accidental Death & Dismemberment

• $100,000 payable for covered loss of life

• Reduced benefits payable for covered losses of fingers or toes

ADDITIONAL COVERAGE

Occupational Hernia Benefit This benefit pays covered medical expenses & weekly income benefits when the hernia arises solely out of and in the course of active

employment and meets ALL of the following five established criteria: 1) sudden onset with 2) sudden pain and 3) sudden swelling and 4) results

from a direct injury and 5) does not result from a condition that previously existed.

Cumulative Trauma Benefit This benefit pays for covered medical expenses, and weekly income benefits same as any other benefit when damage to the physical structure of the body results from repetitious physically traumatic activities that occur solely while the worker is performing the duties of his or her regular job. Cumulative Trauma includes repetitive motion disorders, overuse disorders and Carpal Tunnel Syndrome.

Occupational Disease Benefit This benefit pays covered medical and dental expenses, and weekly income benefits same as any other benefit when a disease caused solely from the performance of the driver’s regular duties results in damage or harm to the physical structure of the body. It includes other diseases or infections that naturally result from the work-related disease. It does not include ordinary disease to which the general public is exposed outside of the worker’s regular duties.

LOSS BENEFIT PAYABLE

Loss of Life 100%

Loss of Both Hands 100%

Loss of Both Feet 100%

Loss of Sight of Both Eyes 100%

Loss of One Hand and One Foot 100%

Loss of One Hand and Sight of One Eye 100%

Loss of One Foot and Sight of One Eye 100%

Loss of Speech and Hearing in Both Ears 100%

Loss of Use of Both Arms 100%

Loss of Use of Both Legs 100%

Loss of Use of One Arm and One Leg 100%

Loss of One Hand 50%

Loss of One Foot 50%

Loss of Sight of One Eye 50%

Loss of Speech 50%

Loss of Hearing in Both Ears 50%

Loss of Use of One Arm or One Leg 50%

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1099 OWNER-OPERATOR DRIVER BLANKET GROUP OCCUPATIONAL ACCIDENT POLICY

IMPORTANT PROVISIONS

ELIGIBILITY If your company has 1-25 owner-operator drivers; is a motor carrier; has been in business for at least one year; has elected to non-subscribe from the Texas Workers’ Compensation system; and your company is not: a seasonal agricultural hauler; a company hauling toxic waste, explosive or hazardous material, nor logging; you may be eligible to participate in this program. Your active 1099 owner-operator drivers age 18 and under 70 are eligible for coverage. Special considerations may be given for companies with more than 25 1099 owner-operator drivers. A subcontractor of the owner-operator driver is not covered.

EFFECTIVE DATE OF COVERAGE You will need to complete and submit Combined’s Owner-Operator Occupational Accident application for underwriting approval. Coverage will begin upon your receipt of a written binder confirmation from Combined. A driver must be actively-at-work for coverage. If a driver is returning to active-at-work, coverage will go into effect on the day after he returns to work for one full day. Each month Combined must receive a Driver Census report and payment for the required premium in order to avoid cancellation of coverage.

RENEWAL GUARANTEE Coverage will stay in effect for each driver until age 70, provided premiums are paid when due, they remain actively-at-work, and the group policy remains in force. Each month Combined must receive a Driver Census report and payment for the required premium in order to avoid cancellation of coverage. BENEFITS PAYMENTS All benefits except those for loss of life are paid directly to the insured.

EXTENT OF COVERAGE CTP benefits as shown are payable for occupational accidents. The aggregate limit of liability for all losses arising out of one accident is $1,000,000.

PLAN EXCLUSIONS Benefits will not be provided for any injury, loss or claims caused directly or indirectly by or resulting from:

1. Suicide or any self-inflicted injury 2. Committing an assault or felony, or being engaged in an illegal occupation 3. War or act of war, whether declared or undeclared 4. Participation in armed services of any country or participation in any riot, rebellion, insurrection 5. Disease, bodily or metal infirmity, nervous or emotional disorders 6. Owned aircraft, unless covered; operating an aircraft under certain circumstances 7. Intoxication or influence of alcohol 8. Narcotics, barbiturates, or other drugs unless prescribed by a doctor 9. Organized competitive athletic events 10. Race or speed contests 11. Commuting to and from work 12. Charges for care provided by a family member 13. Loss for which Workers’ Compensation benefits are payable 14. Charges for care of treatment which is not considered medically necessary, or experimental in nature of conducted for

research purpose

IMPORTANT NOTICE: This brochure is a brief description of the CTP Plan. It is not an insurance contract. Additional conditions, exclusions, and limitations may apply. If a conflict arises between this brochure and the issued policy, the policy will govern.

Send All Completed Enrollment Materials to Combined Group Insurance Services

Call with questions: (800) 275-3193 or (214) 295-1600

Email: cei@combinedgroup.com Website: www.combinedgroup.com

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1099 OWNER-OPERATOR DRIVER

BLANKET GROUP OCCUPATIONAL ACCIDENT POLICY

HOW TO APPLY?

Only licensed agents appointed by Combined Group Insurance Services may submit business: 1. Make sure your insured is eligible for coverage. 2. Complete Combined’s Owner-Operator Occupational Accident application and select the desired Accident Medical and SIR limits. 3. Complete a Driver Census Form. 4. Include a check for the first month’s premium made payable to Combined Group Insurance Services. 5. Premium is based on the number of drivers actively at work on the effective day of the policy. 6. You will receive a written Binder Confirmation with the effective date of coverage. 7. Each month send a Driver Census report and payment for the required premium.

In some instances additional information may be requested.

WHAT’S THE COST? Your premium depends on the plan selected and is subject surcharges based on the insureds loss history and/or safety programs. Rates and coverage must be confirmed in writing by Combined Group Insurance Services.

CTP 1099 OWNER-OPERATOR DRIVER RATES

Per Insured, Per Month

$1,000 SIR $2,500 SIR

Medical Plan Limit $500,000 $1,000,000 $500,000 $1,000,000

Owner-Operators-Drivers $125 $135 $115 $125

Minimum rates in effect as of July 2018. Subject to underwriting, including surcharges based on loss experience and safety programs in place. Rates may change. Self-Insured Retention (“SIR”).

THIS IS NOT A POLICY OF WORKERS COMPENSATION INSURANCE. THE POLICYHOLDER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS COMPENSATION SYSTEM BY PURCHASING THIS POLICY AND, IF THE POLICYHOLDER IS A NONSUBSCRIBER, THE POLICYHOLDER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS COMPENSATION LAWS.

Send All Completed Enrollment Materials to Combined Group Insurance Services

Call with questions: (800) 275-3193 or (214) 295-1600

Email: cei@combinedgroup.com Website: www.combinedgroup.com

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ENROLLMENT CHECKLIST

Group Accident Protection Plan for Owner-Operator Truck Drivers

Company Name: __________________________________________________________________________

Company Address: ________________________________________________________________________

City: ______________________________________________________ TX: Zip: ______________________

Contact Person: _____________________________________________ Phone: ( ) __________________

Email: __________________________________________________________________________________

Broker / Agent’s Name: _____________________________________________ Commission %: __________

Address: _________________________________________________________ Tax ID# ________________

Email: __________________________________________________________________________________

General Agent’s Name: _____________________________________________ Commission %: __________

Address: _________________________________________________________ Tax ID# ________________

Email: __________________________________________________________________________________

Effective Date: ___________________________________________ Date Submitted: __________________

Special Instructions: _______________________________________________________________________

________________________________________________________________________________________

Included Are: ______ Owner Operator Occupational Accident Application for Coverage

______ Broker / Agent Licensing

______ Premium Check (you will be billed for the first month’s premium)

______ Owner Waiver and Driver Census Form

Please Note: You will be billed for one full month’s premium based on the Binder Confirmation. This payment will be pro-rated to the first of the following month. Each month you will send us a Driver Census report and payment for the required premium.

Send All Completed Enrollment Materials to Combined Group Insurance Services

Call with questions: (800) 275-3193 or (214) 295-1600

Email: cei@combinedgroup.com Website: www.combinedgroup.com

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GROUP ACCIDENT PROTECTION PLAN

Group Accident Protection Plan for Owner-Operator Truck Drivers

You must apply for coverage by completing Combined’ Owner-Operator Occupational Accident Application

Owner / Officer Waiver, Contract Labor and Employee Census Form

Company Name: __________________________________________________________________________________

Prepared By: _____________________________________________________Date: ___________________________

Are Officers, Owner and/or Partners to be covered? Yes No

If No, please list individuals to be excluded from coverage:

______________________________________ ___________________________________________

_______________________________________ ___________________________________________

_______________________________________ ___________________________________________

_______________________________________ ___________________________________________

Driver Census

Driver’s Name Social Security

Last four digits only (xxxx)

Date of Birth

Date of Hire

Termination Date

1099 Job Duties