United States Independent Contractor
Resume:
ENROLLMENT FORM
THE UNITED STATES FIRE INSURANCE COMPANY
Administrative Office: 5 Christopher Way • Eatontown, NJ 077243 Under Master Group Policy Number: US1579175
***** * *atum Blvd, Suite 240 Phoenix, AZ 85050
GVW:
Date of Birth:
Policyholder: CMS Business, LLC
Applicant:
Insured Person Name:
Social Security#:
Insured Person Address:
Dispatching Company:
Coverage Elected for Insured Person’s Sub-Contractors: X YES NO Type of Applicant: Independent Contractor
By signing this Enrollment Form, the Applicant agrees to all of the following: 1. To be covered under the above specified Master Group Policy. 2. To make to the Policyholder such payments as may be required for the insurance to be provided in the manner specified by the Policyholder.
3. That all of the statements made in this Enrollment Form are, to the best of my knowledge and belief, true and accurate.
EFFECTIVE DATE OF INSURANCE- The Effective Date of Insurance is the date shown in the Schedule of Benefits in each person's Certificate of Insurance; provided this request has been approved by the United States Fire Insurance Company or its authorized agent, and the proper premium has been paid. PREMIUM: A weekly rate of $11.84 per Independent Contractor. AMOUNTS OF INSURANCE REQUESTED (Applies only to the Applicant specified above) Accidental Death & Dismemberment Benefit
Principal Sum- $200,000
Disability Income Benefit
Temporary Disability- Weekly Benefit – 70% of Average Weekly Earnings, subject to the following:
Maximum - $500 Weekly Benefit minus Other Income Benefits Continuous Total Disability- Monthly Benefit- 4.3 times Average Weekly Earnings multiplied by 0.70, subject to the following:
Maximum - $2,150 minus Other Income Benefits
Accident Medical/Dental Benefit
Maximum Benefit - $500,000 per Occupational Accident Crum OccAcc Enrollment Form_500K Courier_Flat_v15.00 OAC-102018A-EF Page 2
Optional Riders
Non-Occupational Coverage Yes No
Principal Sum for the Accidental Death and Dismemberment Benefit- Maximum Benefit $15,000
Maximum Benefit for the Accident Medical/ Dental Expense Benefit- Maximum Benefit $10,000 per Non-Occupational Accident Cumulative Trauma Coverage Yes No
Maximum benefit- $5,000
Occupational Disease Coverage Yes No
Maximum benefit- $5,000
Hernia Coverage Yes No
Maximum benefit per injury- $5,000
Lifetime maximum benefit- $5,000
Hemorrhoid Coverage Yes No
Lifetime maximum benefit- $5,000
One Sum Option. All benefits under the Accidental Death and Dismemberment Benefit shall be paid in one sum.
Beneficiary Information:
Primary Beneficiary: Relationship:
Signed:
(Signature of Applicant)
Date:
Crum OccAcc Enrollment Form_500K Courier_Flat_v15.00 Blue Star Claims LLC
21001 N. Tatum Blvd., Suite 1630-646, Phoenix, AZ 85050 Phone: 480-***-**** Fax: 480-***-**** Email: ad1lmu@r.postjobfree.com REPORT A CLAIM
Our mission at Blue Star Claims LLC is to always provide prompt and excellent customer service for the independent contractors and contract companies. BLUE STAR CLAIMS OFFERS YOU OPTIONS ON REPORTING NEW CLAIMS: WEB:
WWW.BLUESTARCLAIMS.COM
PHONE:
*For interpreter services, please call iLingo2 at 800-***-**** for assistance in reporting claims FAX:
EMAIL:
ad1lmu@r.postjobfree.com
MAIL:
BLUE STAR CLAIMS LLC
21001 N. TATUM BLVD, SUITE 1630-646
PHOENIX, AZ 85050
Crum OccAcc Enrollment Form_500K Courier_Flat_v15.00 Blue Star Claims LLC
21001 N. Tatum Blvd., Suite 1630-646, Phoenix, AZ 85050 Phone: 480-***-**** Fax: 480-***-**** Email: ad1lmu@r.postjobfree.com LIST EMPLOYER AS: Self Employed BSC
INJURED INDEPENDENT CONTRACTOR CLINICS
If an injured independent contractor needs assistance in finding a treating provider, they can search the following clinic websites for locations near them. The below listed clinics specialize with work related injuries.
https://www.concentra.com/urgent-care-centers/
https://www.ushealthworks.com/Medical-Center/Find.html https://n-o-v-a.com/locations/
Crum OccAcc Enrollment Form_500K Courier_Flat_v15.00 Blue Star Claims LLC
21001 N. Tatum Blvd., Suite 1630-646, Phoenix, AZ 85050 Phone: 480-***-**** Fax: 480-***-**** Email: ad1lmu@r.postjobfree.com DEFINITI RX PRESCRIPTION CARD PROGRAM
Administered by Blue Star Claims LLC
INDEPENDENT CONTRACTORS
• If you need a prescription filled for an occupational accident injury, please call 844-***-**** to get your temporary Member ID #.
• Please take this sheet to any pharmacy and present this sheet to the pharmacy with your Member ID filled out, along with your prescription.
• If your occupational accident claim is accepted, you will receive a more permanent pharmacy card in the mail, via email, or via text message. PHARMACIST
• The independent contractor will have to call to get their temporary Member ID#.
• All data needed to process this script through the Definiti Rx System is included in the drug card represented below.
Crum OccAcc Enrollment Form_500K Courier_Flat_v15.00
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