Disability Benefits Declaration

1.        INDEPENDENT CONTRACTOR STATUS: I acknowledge that I am an Independent Contractor and that is how I qualify for Occupational Accident Benefits.

2.        CURRENT BENEFITS: I am currently eligible for Temporary Total Disability (“TTD”) income benefits and Accident Medical / Dental Expense Benefits (the “Occ Acc Benefits”) under the Occupational Accident Policy (the “Policy”) issued by United States Fire Insurance Company (“Carrier”) and administered by Blue Star Claims LLC (“Blue Star”), the third party administrator for Carrier. I understand that the Policy has an expiration date for Occ Acc Benefits from the Incident Date.

3.        WORK STATUS / TERMINATION OF BENEFIT: In accordance with the terms of the Policy, I understand I am required to provide ongoing current and updated work status from my treating physician(s) when so requested by Blue Star. I understand that my eligibility for ongoing TTD benefits will cease the date I am released to return to work to my regular occupation and/or am no longer eligible for Occ Acc Benefits under the terms of the Policy. I certify I have not returned to work in any capacity (to my regular occupation or any other occupation) since the date of my occupational accident (the “Incident Date”).

4.        OVERPAYMENTS: I understand that if I fail to notify Blue Star of my return-to-work status and it results in an overpayment of TTD benefits, I will be responsible to reimburse Blue Star, on behalf of Carrier, in full. Any subsequent check(s) received after my eligibility for TTD has stopped will be sent back to my adjuster to be corrected, if necessary.  I understand that any overpayments on my TTD claim must be reimbursed to Blue Star in full (including any lump sum benefit(s) I may receive that is/are categorized as Other Income, as further described below). In the event I am unable to reimburse the overpayment in full, Blue Star, in its sole discretion, will determine whether to withhold partial or full monthly benefits until such overpayment is recovered. If applicable, in the event I qualify for Continuous Total Disability (“CTD”) or Permanent Total Disability (“PTD”) benefits under the Policy and have not fully satisfied any TTD overpayment as of the expiration of my TTD benefits, Blue Star will continue to recover any remaining overpayment balance incurred during my TTD claim against my CTD or PTD claim, if applicable.

5.    I understand that if I have any other source(s) of income, I must immediately notify Blue Star. Under the terms of the Policy, I understand that indemnity benefits may be reduced by different types of Other Income including, but not limited to, income from working or running a business; and Social Security Retirement / Income / Disability Benefits; and Unemployment Benefits; and other insurance benefits. The Policy defines Other Income, if applicable.

*If YES, please list Other Income source(s) and attach documentation of the income to this Declaration. If Social Security, provide copy of award or acceptance letter. Put N/A if not applicable.

7.    Prior to, on, or after the Incident Date, have you contracted with any other Delivery Network Company (DNC) or Transportation Network Company (TNC) where the Company is active and/or engaged in either: 1) Delivering Goods/Services; or 2) Driving Passengers (with or without Goods/Services)?               

***If YES, please provide the name of the company(ies), your status with the Company (Active or Inactive), as well as the dates you began and ended contracting with such company(ies). Put N/A if not applicable.

8.    RIGHT OF RECOVERY / SUBROGATION: If applicable, I also understand that if I make a claim for damages against another person or entity arising out of my occupational accident and/or injuries, Blue Star may assert US Fire’s Right of Recovery rights under the Policy and file a Right of Recovery for indemnity benefits and/or any “Covered Expenses” (as that term is defined in Policy) that were paid through the Accident Medical / Dental Expense provision under the Policy against any third-party recovery I may receive.

FRAUD WARNING

Any person who knowingly, and with intent to defraud or deceive Us or any other person, makes a Request for Insurance or any claim for the proceeds of the Policy containing any false, incomplete or misleading information may be guilty of a crime.

Please see following pages for state specific requirements.

FRAUD WARNING: RESIDENTS OF NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION

CLAIM FORM FRAUD STATEMENT - FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an

application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

ALASKA: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

FLORIDA WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

KANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of insurance fraud as determined by a court of law and may be subject to fines and confinement in prison.

KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

NEW JERSEY:  Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NEW MEXICO and PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

OKLAHOMA: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

TENNESSEE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

TEXAS:  Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

VIRGINIA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.                                                                                                                                 CF 0117