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Occupational Accident Benefits Program
Hidden
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Â
Â
$105.00 per month
Â
ACCIDENTAL DEATH
$100,000
Â
ACCIDENTAL DISMEMBERMENT
$100,000
Â
TEMPORARY TOTAL DISABILITY
$250 / 52 ​weeks
Â
CONTINUOUS TOTAL DISABILITY
$250 / to age 65
Â
ACCIDENT MEDICAL EXPENSE
104 ​weeks / $50,000
Â
Learn more.....
Â
SIGN UP
O-Optimal
Â
Â
$130.00 per month
Â
ACCIDENTAL DEATH
$105,000
Â
ACCIDENTAL DISMEMBERMENT
$100,000
Â
TEMPORARY TOTAL DISABILITY
$250 / 52 ​weeks
Â
CONTINUOUS TOTAL DISABILITY
$250 / to age 65
Â
ACCIDENT MEDICAL EXPENSE
104 ​weeks / $1,000,000
Â
Learn more.....
Â
SIGN UP
P-Pro
Â
Â
$160.00 per month
Â
ACCIDENTAL DEATH
$155,000
Â
ACCIDENTAL DISMEMBERMENT
$150,000
Â
TEMPORARY TOTAL DISABILITY
$750 / 52 ​weeks
Â
CONTINUOUS TOTAL DISABILITY
$250 / to age 65
Â
ACCIDENT MEDICAL EXPENSE
104 ​weeks / $1,000,000
Â
Learn more.....
Â
SIGN UP
Coverage Effective Date
Select Effective Date
*
MM slash DD slash YYYY
Hidden
Data entry type
*
Enter persons manually
Import persons to cover from a file
CSV File structure - comma or semicolon separated driver list.
Select a file on your computer that contains the data that you would like to import, or download the template to get a head start on creating the import file.
Hidden
CSV content
Import type
*
Import from file
Copy paste CSV content manually
Choose CSV delimiter
*
comma (,)
semicolon (;)
Upload CSV file
Download Import File Template:
sample CSV
sample XLS
CSV Content
*
You can enter or paste CSV content directly into the table below.
First name, Last name, Occupation, SSN, Drivers License, State, DOB (mm/dd/yyyy), Gender (M/F), Email, Phone, Street, City, State, Zip, Benifieciery (Y/N), Benifieciery firstname, Benifieciery lastname, Benifieciery phone
Live data validation as you type in this field is presented in the box below.
*
Green
- field valid,
Yellow
- incorrect column number,
Red
- invalid field
Covered Drivers - Members
*
To add additional drivers information click on "Add a member".
To make any changes for existing drivers click on "Edit"
Name
Date of Birth
License #
Email
Phone
GOP Plan
Do you want to select contingent liability for drivers?
*
Yes
No
Additional information to Underwriter
Optional Coverages
Select optional coverages for each covered driver
Covered driver
Contingent Liability
Thank you for applying for TOA Occupational Accident Program coverage.
Based on the information you have provided, we are pleased to provide you with the price indication below.
Please review and confirm that all information entered is correct. In order to proceed, an initial payment is required to bind coverage.
Price Indication PDF
Confirmation
Please check to confirm
*
I confirm all information entered is correct and would like to bind coverage.
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