Terms & Conditions
Please Read Carefully
It is further understood and agreed:
1. Not Statutory Workers’ Compensation & Employers’ Liability: This coverage is NOT a statutory Workers’
Compensation and Employers’ Liability policy and the benefits under this policy do not necessarily equal the benefits which an individual might be eligible for under statutory Workers’ Compensation. However, the Insured Person agrees that in the event of an occupational accident, he will look to this program in lieu of seeking Workers’ Compensation coverage.
2. Assignment of Benefits: In the event benefits are paid from the statutory Workers’ Compensation and Employers’ Liability Policy of the sponsoring company or any similar policy becomes liable for such benefits, the benefits which an Insured Person is entitled to under this policy will be automatically assigned to the sponsoring company. Therefore, in such event the Insured Person hereby agrees to the immediate assignment to the sponsoring company of all benefits which he receives or would otherwise be payable to him or any third party under this program.
3. Cost and Consent to Rate Change: The Insured Person understands that the insurance cost shown may include taxes, fees and administrative expenses which he accepts and acknowledges as part of the insurance cost. The insurance underwriters reserve the right to change the rate by giving written notice to you.
4. Evidence of Coverage: Your state of principal operations could require you to purchase Statutory Workers Compensation; otherwise, the sponsoring company will accept this Independent Contractor Occupational Accident Program. If you do not participate in this Occupational Accident Program, you are required to have on file a certificate of insurance for Statutory Workers’ Compensation or when allowed by law, an Occupational Accident Certificate; your insurance agent should provide this information to the sponsoring company.
You will be enrolled in the Independent Contractor Program until you provide proof of appropriate coverage. At that time you will receive an adjustment in any costs charged to you.
5. Termination: In the event the contractor’s lease agreement with the sponsoring company is terminated for any reason by either party, the Occupational Accident coverage will be cancelled effective the date of the contract termination or the earliest date thereafter allowed by law. You should make arrangements to replace coverage immediately.
6. Terms & Conditions: Coverage will be subject to all policy terms, conditions and exclusions as detailed in the Evidence
of Insurance. The Insured Person must be under age 75 to enroll in the plan.
7. Authorization of Settlement Deduction: You, the Independent Contractor, authorize the sponsoring company to take from your settlement checks, funds, accruals or other compensation, on a periodic basis (e.g. weekly or monthly) in amounts sufficient to pay the cost of premiums and taxes and hereby instruct it to forward direct to Midlands Management such amounts by the due date each month. Your cost (as described in “Cost and Consent to Rate Change”) will be deducted from your settlement check. If your settlement check is not enough to cover the insurance cost to you, you will be asked to forward a check or money order made payable to Midlands Management, P.O. Box 22778, Oklahoma City, OK 73123 immediately, or the coverage will be cancelled, in accordance with policy terms and conditions.
8. Effective Date: Coverage shall become effective on the date your application is accepted by Midlands Management but no sooner than the first day of the month following your completion and signing of this enrollment form.
Acrisure of California, LLC license number of 0K07568.
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