Occupational Accident Benefits Program

This field is hidden when viewing the form
PDF log
Agent information. Application filled by
Your name*
First Last
Your phone*
Your email*
Please enter agency National Producer Number (NPN) number*
Does customer (Sponsor) have a DOT number?*
- Yes
- No
Please enter DOT number*

Account Info
Customer/Sponsor is acting as*
- Company
- Individual
Owner's Name on the Certificate*
Sponsor's Name on the Certificate*
First Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
- This is individual account, not a company
- Customer is also Doing Business As
DBA Name*
Phone
Updated phone
Sponsor's Email Address

AVAILABLE PLANS

Occupatonal Accident GOP plan*

G-Good

$105.00 per month

ACCIDENTAL DEATH

$100,000

ACCIDENTAL DISMEMBERMENT

$100,000

TEMPORARY TOTAL DISABILITY

$250 / 52 â€‹weeks

CONTINUOUS TOTAL DISABILITY

$250 / to age 65

ACCIDENT MEDICAL EXPENSE

104 â€‹weeks / $50,000

Learn more.....

O-Optimal

$130.00 per month

ACCIDENTAL DEATH

$105,000

ACCIDENTAL DISMEMBERMENT

$100,000

TEMPORARY TOTAL DISABILITY

$250 / 52 â€‹weeks

CONTINUOUS TOTAL DISABILITY

$250 / to age 65

ACCIDENT MEDICAL EXPENSE

104 â€‹weeks / $1,000,000

Learn more.....

P-Pro

$160.00 per month

ACCIDENTAL DEATH

$155,000

ACCIDENTAL DISMEMBERMENT

$150,000

TEMPORARY TOTAL DISABILITY

$750 / 52 â€‹weeks

CONTINUOUS TOTAL DISABILITY

$250 / to age 65

ACCIDENT MEDICAL EXPENSE

104 â€‹weeks / $1,000,000

Learn more.....

Occupational Accident Benefits Program

Agent information. Application filled by

Account Info

AVAILABLE PLANS

Coverage Effective Date

Optional Coverages

Confirmation

Log In

Covered driver	Contingent Liability