INDEPENDENT CONTRACTOR

ACCIDENT INSURANCE

ADMINISTRATIVE MANUAL

UNDERWRITTEN BY:

AEGIS SECURITY INSURANCE COMPANY

P.O. BOX 3153 Harrisburg, PA 17105-3153

PROGRAM AGENT:

WILSON GREGORY AGENCY INC.

P. O. BOX 8 Camp Hill, PA 17001-0008 PHONE: (717) 730-9777

FAX: (717) 730-9328 E-MAIL: info@wilsongregory.com

1

GENERAL INFORMATION Thank you for choosing Wilson Gregory Agency for your Independent Contractor insurance needs. Wilson Gregory Agency Inc. (WGA) has served the Independent Contractor Accident Insurance and Surety Bond needs of Circulation Departments in over 1000 daily newspapers throughout the United States since 1923. By providing the newspaper industry with affordable and innovative insurance programs and unparalleled service, Wilson Gregory Agency has become the industry leader in the Independent Contractor accident insurance business. The comprehensive Wilson Gregory website, www.WilsonGregory.com, provides immediate access to the tools necessary for Circulation Departments and Distribution Companies to understand, train and administer these programs.

POLICIES AND COVERAGES All Surety Bond Programs are underwritten by Aegis Security Insurance Company, Rated A (Excellent) by A.M. Best Company. Accident Insurance Programs are underwritten by Aegis Security Insurance Company and Life Insurance Company of North America, A Cigna Company, Rated A (Excellent) by A.M. Best Company. All accident policies are designed to provide protection against accidental bodily injury sustained as the direct and independent result of all types of accidents occurring both on and off-route. Combining EXCESS on-route coverage with generous 24-hour (off-route) benefits ensures affordability, participation and Maximum Publisher Protection. All 24-hour benefits (off route) are paid in addition to any other source(s) of insurance, and a substitute contractor is covered automatically while on-route only performing the duties associated with route delivery in the absence of the Contractor of Record. All claims are processed within 48 hours of receipt to insure the fastest turn around time in the industry.

ADMINISTRATION Installation of WGA accident policies are handled by agents licensed to transact insurance in your state. Our agents will handle all details thoroughly and periodically brief your department personnel relative to program administration. All supplies required to sponsor a program are furnished by Wilson Gregory Agency and can easily be phased into those administrative procedures currently in use in your department, making it easier for you to move your Independent Contractor coverage to the company of choice, Wilson Gregory Agency.

OPINIONS

Newspapers across the United States enthusiastically endorse WGA's Independent Contractor programs for many reasons:

Premiums are paid by the carrier, further strengthening the Independent Contractor relationship;

Payment of claims reduces the danger of legal action against the newspaper when serious on-route accidents occur;

Benefit payments are made directly to the insured unless benefits are assigned to a provider;

Protection extends to include coverage while on newspaper sponsored trips and outings, as well as for a substitute contractor; and

Provides your publication with a tremendous amount of good will by paying a multitude of off-route claims while protecting the publisher where it is needed most, on-route.

ADMINISTRATIVE FACT SHEET In order to help you better understand Independent Contractor Newspaper Carrier Accident Insurance, the following list highlights some important points:

1. This is a supplemental group accident only policy, paying benefits for accidental bodily injury incurred as the direct and independent result of an accident.

2. Coverage is provided 24 hours per day, 7 days per week, 365 days per year. All 24 hour benefits are paid in addition to and irrespective of any other insurance contracts. On-route benefits are paid in excess of any other primary source of insurance. If no other primary form of insurance exists, benefits are paid from first dollar up to the policy limits.

3. On-route is defined as: (1) delivering newspapers to subscribers; delivery begins with delivery to the first subscriber and ends with delivery to the last subscriber without deviation and outside the property line of the Insured; (2) collecting payments from subscribers; (3) soliciting non-subscribers on an established route; or (4) while on a bona fide trip or outing authorized and sponsored by, and as a guest of the newspaper.

4. Policy exclusions are suicide, sickness, hernia (however sustained), warfare (declared or undeclared), Carpal Tunnel Syndrome, Bursitis, Tendonitis, illegal activity and drug and alcohol related accidents.

5. Age limits are 9 to 90, with half benefits for contractors over age 65. Contractors 18 and older should be insured under a separate adult policy unless only one program is sponsored by the newspaper.

6. The WGA Discount Prescription Drug plan provides discounts on all FDA-approved prescription drugs. Discount cards are provided as an extra benefit to insureds and their families. (These cards are Not Insurance, but are discounts only.)

7. A Substitute is covered on-route only while performing route duties in the absence of the contractor of record. However, helpers who regularly assist or accompany the contractor on-route are not covered under the terms and conditions of the policy and should be insured under their own policy.

8. Medical treatment for any compensable injury must begin within ten (10) days from the date of accident (30 days in Pennsylvania), and all claims must be filed and received by the insurance company within 90 days from the date of accident. Should extenuating circumstances arise and these time limits pose a problem, simply notify WGA prior to expiration of the time limits to request an extension. (Individual Independent Contractors can print a claim form directly from www.WilsonGregory.com.)

9. Premiums are added to the contractor’s bill or deducted from the contractor’s check. Premium payments, payable to Aegis Security Insurance Company are remitted to the insurance company monthly, in arrears. That is premiums are due the 10th of the month for the preceding month’s coverage.

10. The following Learning Center Modules are available on-line at www.WilsonGregory.com:

Module 1: Introduction to Independent Contractor Status & Accident Insurance

Module 2: The Enrollment System

Module 3: Premium Overview

Module 4: Claims Form Overview

COORDINATION OF BENEFITS EXPLANATION

The Independent Contractor Accident Insurance Policy in use at your newspaper is a supplemental accident only policy, paying benefits for bodily injury sustained by an Insured as the direct and independent result of an accident. This is a limited, group accident only policy and should not be confused with any primary source of insurance, such as a comprehensive health plan or major medical plan. It is designed to cover the out of pocket expenses associated with co-insurance and deductibles found in today's primary health care plans. In an effort to help control costs and keep premiums as low as possible, this policy contains an “Excess" or "Coordination of Benefits" clause for the on-route portion of the policy. This means on-route benefits are paid only for excess expenses incurred which are not covered by any other primary source of insurance, up to the policy limit. If no other source(s) of insurance exists at the time the accident occurs, covered expenses are paid from first dollar up to the policy limit. If other insurance pays 100% of all covered expenses, then benefits are paid according to the 24-hour (off-route) portion of the policy, so the insured Independent Contractor always receives a benefit for the paid premium dollar.

In order to expedite claim settlement, administration and maintain 48- hour turn around service, the Independent Contractor must fully complete the following information on the claim form *:

1. Full name, date of birth, and social security number of Insured;

2. List all other source(s) of insurance in the section provided in Part 1, Claimant's Statement. This section must be completed in full, all questions answered, and all blanks filled in properly. Claim settlement will be delayed until this section is fully completed;

3. Attach all explanation of benefit (EOB) statements from any other insurance source,

indicating benefit amounts covered or denied and coinsurance payments made. Also attach any other evidence indicating payment of medical, hospital, or doctor bills such as canceled checks or receipts of payment. Send additional bills as received if this would delay submitting the claim form.

Should any questions arise regarding the above or if Wilson Gregory Agency may be of any additional help in answering questions regarding claim submission, please don't hesitate to call (717) 730-9777.

A properly completed claim form must be filed and received by the insurance company within 90 days from the date of Accident.

* Claim forms can be downloaded at www.WilsonGregory.com by clicking on “HOW TO FILE A CLAIM”

INDEPENDENT CONTRACTOR ACCIDENT INSURANCE FORMS

Newspapers and Distribution Companies may print these forms directly

from the content managed area of the WGA website – www.WilsonGregory.com. Following is an explanation of the forms associated with your Independent Contractor Accident Insurance Program: FACT SHEET/CHECKLIST (available on-line) – The Checklist serves to clearly document the Independent Contractor’s understanding and acceptance (or rejection) of the Accident Insurance, while the Fact Sheet is an easy to read introduction for the new/uninsured Contractor. ENROLLMENT/REJECTION CARDS (available on-line) – One or the other of these cards MUST be completed anytime an Independent Contractor is contracted for a route. If a contractor enrolls in the program, the enrollment card must be completed in full and signed by the contractor. If the contractor is a youth under age 18, a parent or guardian must sign the enrollment card where indicated. If coverage is rejected, the contractor MUST complete and sign the rejection card. File either card in the corresponding route file so at all times you have an accurate record of who is insured and who is not. Please note, Contractors are insured not routes. Contractors delivering multiple routes should only be enrolled once and charged one premium. CERTIFICATE (available on-line) – Anytime a Contractor elects coverage, the corresponding certificate of coverage for that program MUST be issued explaining the coverage contained in the policy. The certificate is simply a description of benefits. The Master Policy is on file and available for reference at the newspaper office. If coverage is rejected, no certificate is issued. MONTHLY PREMIUM STATEMENT (available on-line) –The premium statement is a form with three separate graphs. One (1) graph should be completed monthly for each accident insurance policy. Complete each graph according to the billing cycle in use at your newspaper. Refer to the enclosed sample for examples of the various billing cycles. A sample of a properly completed premium report is included for your review.

All accident insurance premium checks should be made payable to: Aegis Security Insurance Company.

Attach an itemized list of enrollees*, include a check for the total premium, and send to WGA, P.O. Box 8, Camp Hill, PA 17001-0008 no later than the 10th day of the month following the month for which coverage is provided.

Without timely submission of premiums, claim settlement will be delayed. An example of a properly completed premium statement is included for your review.

* The list of enrollees may be sent via e-mail to Wendy@wilsongregory.com instead of attaching a paper list. A PDF format is preferred.

INDEPENDENT CONTRACTOR ACCIDENT INSURANCE FORMS (continued) CLAIM FORM (available on-line): Note: Instructions for completing this form are outlined in paragraphs A - F at the top of the claim form. Additional details are listed on another form in this brochure titled "Guidelines for Submitting Claims." A sample of a properly completed claim form is included for your review. It is the responsibility of the Circulation Department to provide an insured contractor with a claim form immediately after being notified an accident occurred.

SPECIAL "ON-ROUTE" ACCIDENT REPORT FORM (top of last page of claim form) In the event of an "on-route" accident, this part of the claim form must always be completed by the newspaper. It should be accurately completed, signed and dated by the investigating newspaper representative in letters "A thru O," and signed in letter “P” evidencing the claim has been investigated as on-route accident.

LETTER OF RECOMMENDATION (bottom of last page of claim form) In addition to completing the SPECIAL “ON-ROUTE” ACCIDENT REPORT FORM, the “Letter of Recommendation” section at the bottom of this page must also be completed, dated and signed by a person authorized by the newspaper to verify on-route accidents and whose signature is on file with the insurance company. Claims submitted without an authorized signature or unsigned will not be honored as on-route claims.

AUTHORIZED SIGNATURE CARD An Authorized Signature Card must be on file with the insurance company at all times. This form lists those individual (s) authorized to complete the LETTER OF RECOMMENDATION section of the SPECIAL ON-ROUTE REPORT FORM. Should authorized personnel change or should the Authorized Signature Card need amended for any reason, simply contact WGA and a new one will be sent immediately. Please contact your agent or call Wilson Gregory Agency at 717-730-9777 if you have any questions regarding these forms.

Accident Insurance You Can’t Afford To Be Without

• Didyouknowyouarenotcoveredby workers’compensation?

• Didyouknowthatover90%ofallreported accidentsoccurOn-Route?

• Didyouknowmosthealthinsurancecompanies canDENYpayingmedicalbenefitsforwork relatedinjuries?• Didyouknowmostautoinsurancecompaniescan DENYClaimsforbusinessrelatedautoaccidents?• DidyouknowYOUareresponsibleforyour Substitute,NOTtheNewspaper?• IfyourSubstituteisinjureddeliveringyourRoute, canYOUaffordtopaytheirmedicalbills?

Don’t Wait Until You’re Injured To Find Out You’re Not Insured

• Paysbenefitsforaccidentalbodilyinjury• Provides24-hourcoverage• SubstituteautomaticallycoveredOn-Routeonly atnoadditionalcost• Helpers,spouses,children&dependents, ages9-90,canenroll• Premiumsare100%deductiblefor self-employedContractors

Because Unpaid Medical Bills Could Leave You Broke

• AffordablecoverageOn&Off-Route• ExcessOn-Routemedicalcoverage• Off-RouteBenefitspayINADDITIONto othercoverage• LossofLifeBenefitspayabletoa namedbeneficiary• PaysweeklyDisabilityBenefit

• PaysContractorsdirectlyWhy Risk It ?It’s Easy To Pay For

It’s Simple to Get It’s Insurance You Need www.WilsonGregory.com

As the Independent Contractor of Record, I understand that I am solely responsible for any injuries that may happen to me, my Substitute, or my Helper(s) while my contract is in force.

I understand that an Accident Insurance policy is available.

I understand this is a limited supplemental accident only policy that pays Medical, Disability, Loss of Life & Dismemberment Benefits if an injury occurs as the result of an accident.

I understand On-Route coverage coordinates with primary insurance if applicable.

I understand the Accident Insurance policy automatically covers a Substitute, one individual On-Route only.

I understand if my Substitute is injured delivering my Route, I am responsible for their medical bills.

I understand that my Helper(s) is/are not covered under my Accident Insurance policy and that I must first be enrolled in order for my Helpers to be eligiable to enroll in their own policy, and

I understand that individuals ages 9-90 can enroll with half benefits over age 65.

By my signature below, I acknowledge that I have read this document, both the Factsheet and Checklist, in its entirety and understand the contents. Additionally, I understand this document will be made part of my permanent Route file.

Contractor Name (print) Contractor Name (signature) Route # Date

Newspaper Name City State

Newspaper Representative Name (print) Newspaper Representative Name (signature)

Title Date

CHECKLISTACCIDENTINSURANCE

GUIDELINES FOR COLLECTING PREMIUMS AND REMITTING PREMIUM REPORTS

Each month it is the responsibility of the circulation department / distribution company to properly complete a premium reporting form and remit it to WGA along with a list of enrollees, and a check for the correct premium amount due that month. Premiums are added to the contractor’s bill or deducted from the contractor’s check depending on the type of billing system(s) and cycle(s) in use at your company. Premiums are due by the tenth (10th) of each month. Premiums are collected from contractors in arrears. That means each month premiums are due for the previous month’s coverage. The accident insurance program insures individual contractors not routes. Therefore only one (1) premium should be charged per contractor no matter the number routes delivered. Wilson Gregory Agency does not invoice or bill the newspaper. The accident insurance program is a self billing system. A sample of a properly completed premium report is included for your review. The premium reporting form is available on-line at www.WilsonGregory.com. It contains three (3) separate graphs. Each month one (1) graph should be completed for each accident insurance program in force at your company. Complete each graph according to the type(s) of billing cycle(s) in use. (See Sample on next page.) All premium checks should be made payable to: Aegis Security Insurance Company To calculate premium(s) due for each program in force at your newspaper, enter the week, month or period ending information in row # 1 of each graph on the premium report. In row # 2, enter the total number of eligible contractors for each program. Generate an itemized list of insured contractors for each program and enter that number in row # 3. Do the same for any newspaper people enrolled and enter that number in row #4. Add together rows #3 and #4 and enter that number in row #5. Multiply the total number enrolled by the premium rate and enter the premium due in row #7. Add together the premium due for each program and enter the total for all programs in the corresponding block in the lower right hand corner of the form. Attach an itemized list of enrollees (this may be sent via e-mail to Wendy@wilsongregory.com instead of attaching a paper list) and include a check for the total premium due and mail to WGA so that it is received by the tenth (10) of the month. WITHOUT TIMELY SUBMISSION OF PREMIUMS, CLAIM SETTLEMENT WILL BE DELAYED.

Wilson Gregory Agency, Inc. 2309 Market Street

P.O. Box 8 Camp Hill, PA 17001-0008

(717) 730-9777

Newspaper Name City State

Monthly Premium Report For Month Ending

Contact Name Telephone

Use this space for ordering supplies or any other short correspondence

SRX # ________

FOR INDEPENDENT CONTRACTORS

BILLED WEEKLY

FOR INDEPENDENT CONTRACTORS

BILLED MONTHLY 1. Week ending

2. Number of eligible independent contractors

3. Number of independent contractors enrolled for insurance

4. Number of supervising persons enrolled for insurance

5. Total enrollment for insurance

6. Premium rate

7. Total premium due

TOTAL PREMIUM DUE

SRX # ________

FOR INDEPENDENT CONTRACTORS

BILLED WEEKLY

FOR INDEPENDENT CONTRACTORS

BILLED MONTHLY 1. Week ending

2. Number of eligible independent contractors

3. Number of independent

contractors enrolled for insurance

4. Number of supervising persons enrolled for insurance

5. Total enrollment for insurance

6. Premium rate

7. Total premium due

TOTAL PREMIUM DUE

SRX # ________

FOR INDEPENDENT CONTRACTORS

BILLED WEEKLY

FOR INDEPENDENT CONTRACTORS

BILLED MONTHLY 1. Week ending

2. Number of eligible independent contractors

3. Number of independent contractors enrolled for insurance

4. Number of supervising

persons enrolled for insurance

5. Total enrollment for insurance

6. Premium rate

7. Total premium due

TOTAL PREMIUM DUE

SRX # ________

FOR INDEPENDENT CONTRACTORS

BILLED WEEKLY

FOR INDEPENDENT CONTRACTORS

BILLED MONTHLY 1. Week ending

2. Number of eligible independent contractors

3. Number of independent contractors enrolled for insurance

4. Number of supervising persons enrolled for insurance

5. Total enrollment for insurance

6. Premium rate

7. Total premium due

TOTAL PREMIUM

DUE

TOTAL OF

ALL

PROGRAMS

GUIDELINES FOR SUBMITTING ACCIDENT CLAIMS

It is the responsibility of the Circulation Department to provide an insured contractor with a claim form immediately after being notified an accident occurred. The form is available on-line at www.WilsonGregory.com and selecting “HOW TO FILE A CLAIM”. The following sections must always be completed PRIOR to issuing the claim form to the contractor:

1) Part III, Enrollment Verification. If the claim occurred on-route, the following two (2) sections must also be completed in addition to Part III:

2) Special “On-Route” Accident Report form; 3) Letter of Recommendation Section for on Route Accidents

Once the newspaper has signed off and provided the claim form to the contractor, all additional claim filing requirements become the sole responsibility of the contractor. It is the responsibility of the contractor to insure Parts 1, 2 and 4 of claim form are completed in full, signed where required, attach all itemized medical/hospital/doctors bills and send to the insurance company. All additional correspondence regarding the claim will be handled directly between the insurance company claims department and the contractor, including claim checks, requests for additional information, medical forms etc. Part One Claimant’s Statement: To be completed by contractor. Independent Contractor must complete all questions. Be sure to provide other insurance information, including auto insurance, where requested. Part Two Authorization Statement: To be completed by contractor. Independent Contractor must sign and date authorization to obtain information. If a youth contractor, parent/ guardian must sign Part 2. Part Three Enrollment Verification: To be completed by the newspaper. Prior to issuing the claim form to the contractor, it is the responsibility of the newspaper to verify contractor was enrolled in the program prior to the date of accident and include a copy of the contractor’s newspaper bill or check disbursement evidencing premium was being paid at the time of the accident occurred. Complete each line including authorized signature, premium amount and account number.

Part Four Attending Physician Statement: To be completed by the attending physician. All applicable sections must be completed in full. If claiming total disability, box #18 must be completed by the physician with from/to dates. Special “On Route” Accident Report Form: If accident occurred on-route, a newspaper representative must complete the Special “On-Route” Accident Report Form, letters “A thru O” on back page of claim form and signed where indicated in item “P” that the accident was investigated as an on route accident. Additionally, the “Letter of Recommendation” section at the bottom of this page must also be completed, dated and signed by a person authorized by the newspaper to verify on-route accidents and whose signature is on file with the insurance company. Claims submitted without an authorized signature or unsigned will not be honored as on-route claims. On Route is defined as: (1) Delivering newspapers to subscribers. “Delivery begins with delivery to first subscriber and concludes with delivery to last subscriber without deviation and outside the property line of the insured; (2) Collecting from subscribers; (3) Soliciting non-subscribers on an established route; (4) on an authorized Company sponsored trip or outing. Please note the following time requirements must be fulfilled in order for the claim to be

Medical treatment must be received within ten (10) days of the date of accident (30 days in Pennsylvania);

Completed claim forms and itemized bills must be received by the insurance company within ninety (90) days of the date of accident;

If injury(s) involve an auto accident, a copy of the police report must be submitted with the completed claim form.

Contractors should send all required claim information to:

AEGIS SECURITY INSURANCE COMPANY ACCIDENT INSURANCE CLAIMS DEPARTMENT

2407 PARK DRIVE P.O. BOX 61140

HARRISBURG, PA 17106-1140 PHONE: 717.540.0600

TOLL FREE: 800.692.7338 FAX: 717.657.9499

E-MAIL: info@wilsongregory.com

Aegis Security Insurance Co. ACCIDENT CLAIMS P.O. Box 61140, Harrisburg, PA 17106-1140 • Phone 1-800-692-7338

CLAIM BLANK For benefits under your Independent Contractor

newspaper carrier accident insurance policy.

A. All claims must be filed and received by the insurance company within

90 days from the date of Accident.

B. Insured must complete Parts I and II.

C. Attending Physician must complete Part IV.

D. Newspaper must complete Part III; and

E. Newspaper must complete Special “On-Route” Accident Report, if

applicable.

F. Mail itemized bills and completed claim form to the indicated address

above.

“Warning: Any person knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claims

containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent

act, which is a crime and subject to criminal and civil penalties.”

Part One CLAIMANT’S

STATEMENT

Name of Newspaper Harrisburg Patriot News, Harrisburg, PA Route No. # 241-B City & State

Name of Claimant (PLEASE PRINT) Jane Alice Doe

First Middle Last

Independent Contractor Substitute Independent Independent Contractor

Social Security No. 123-45-1234 of Record √ Contractor Helper

Street Address 2309 Market Street City Camp Hill State PA Zip 17011

Phone No. (717 ) 730-9777 Date of Birth January 15, 1950 Area Code Date of Accident (MM/DD/YY) 01 / 18 / 2002 Time 5:30 AM PM

Where did Accident happen? 1203 10 th St. How did accident happen? I tripped

on the curb. I fell and broke my arm. If automobile accident, attach copy of police report.

What injury did you receive? Broken arm.

If youth, do either of your parents work? Yes No If adult, do you have other work? Yes No

If youth, Father’s Name Mother’s Name First Middle Last First Middle Last

FATHER’S EMPLOYER/YOUR EMPLOYER NAME AND ADDRESS OF EMPLOYER PHONE NO.

MOTHER’S EMPLOYER NAME AND ADDRESS OF EMPLOYER PHONE NO.

Have you received or are you eligible to receive benefits from any of the following: NAME AND ADDRESS OF COMPANY POLICY NO

Yes No Auto Insurance

Yes No School Insurance Yes No Individual Group Insurance BC/BS Camp Hill, PA 11-111 Yes No State or Federal Aid

Yes No Any other source of insurance

List names, addresses and treatment dates of all Doctors consulted for this injury:

Doctor’s Name Street Addresses Cities and States Robert Little, MD 1900 Market St. Camp Hill, PA List ALL At Doctor’s Office 1-19-02, 1-21-02 Dates of

Treatment At Hospital 1-21-02

Were you treated at the hospital for this injury? Yes √ No.

Name of Hospital HOLY SPIRIT HOSPITAL

If Yes Address of Hospital 122 Erford Rd. City Camp Hill State PA

Date Admitted 1-21-02 Date Discharged 1-23-02

Did you lose time from your newspaper route? Yes √ No If yes, attach physician orders

If From Month January Date 19 Year 2002 At 6 o’clock A M

Yes To Month Date Year At o’clock M

If you did not return to your newspaper route, when did you resume other activities? Month Undetermined Date Year At o’clock M

CLAIMANT MUST ALSO COMPLETE PART TWO ON NEXT PAGE. CL1 01/2004

Part Two AUTHORIZATION STATEMENT – Claimant must complete along with Part One.

THIS MUST BE SIGNED AND RETURNED WITH COMPLETED CLAIM FORM

AUTHORIZED TO OBTAIN INFORMATION

TO PHYSICIANS OR PRACTITIONERS, HOSPITAL, CLINICS, PHARMACISTS, INSURANCE

COMPANIES, MEDICAL INFORMATION BUREAU, EMPLOYERS AND OTHER PERSONS OR

INSTITUTIONS: This authorizes you to give Aegis Security Insurance Company or its authorized representative

engaged to assist in the evaluation of the claim of the undersigned, any information, data or records you have

regarding employment and any condition (including records pertaining to psychiatric, drug or alcohol use and

history, and any disability). I understand that such information is confidential and as such Aegis Security

Insurance Company is requested not to furnish any such information to anyone other than the aforementioned

without written authorization from me. I understand that any information obtained pursuant to this authorization

will be used to evaluate this claim and may be transferred to any agency or individual engaged or contracted by

Aegis Security Insurance Company to assist. This authorization is valid unless I revoke it by writing Aegis

Security Insurance Company. I understand I have the right to request a copy of this authorization. A photocopy

of this authorization may be accepted by you.

January 31, 2002

DATE

Jane Doe

SIGNATURE OF INDEPENDENT CONTRACTOR/CLAIMANT SIGNATURE OF PARENT (if independent contractor is a minor)

Jane Doe

Print Name Print Name

“Warning: Any person knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claims containing

any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime

and subject to criminal and civil penalties.”

Part Three TO BE

COMPLETED

BY THE

NEWSPAPER

PRIOR TO ISSUING

TO CONTRACTOR

Name of Regular Carrier Jane Doe

Regular Carrier Became insured on (Date) 12/1/01

Policy No. SGL-23000 Acct. # SRX-97084

Check One: Youth Independent Contractor Adult Independent Contractor Helper Independent Contractor

If Claim is being filed for a Substitute Independent Contractor, check here

Comment

Name of Newspaper PATRIOT-NEWS City Harrisburg, PA

By Joyce Connell, Circulation Office Mgr. Date 1/31/02

Authorized Signature only as contained on authorized signature card.

ATTENTION TO EXPEDITE PAYMENT OF THIS CLAIM AND MAKE SURE IT IS PAID CORRECTLY

PLEASE CHECK YOUR BILLING RECORDS AND INDICATE THE WEEKLY OR

MONTHLY PREMIUM THIS CARRIER IS PAYING.

WEEKLY $ . MONTHLY $ 7 . 50 ACCT.# 97084

As proof of insurance in force, a copy of the last paper bill on which premium was charged or

check disbursement showing premium deducted must accompany this claim form.

THANK YOU

Part Four ATTENDING PHYSICIAN’S STATEMENT – Must be completed by attending physician or if Independent

Contractor lost time from the route.

HEALTH INSURANCE CLAIM FORM READ INSTRUCTIONS BEFORE COMPLETING OR SIGNING THIS FORM

TYPE OR PRINT MEDICARE MEDICAID CHAMPUS OTHER

PATIENT & INSURED (SUBSCRIBER INFORMATION) 1. PATIENT’S NAME (First name, middle initial, last name)

Jane Doe

2. PATIENT’S DATE OF BIRTH

01 / 15 / 1950

3. INSURED’S NAME (First name, middle initial, last name)

Jane Doe 4. PATIENT’S ADDRESS (Street, City, State, ZIP code)

2309 Market St. Camp Hill, PA 11-1111

5. PATIENT’S SEX

MALE X FEMALE

8. INSURED’S ID No or MEDICARE No (include any letters)

123-45-1234 7. PATIENT’S RELATIONSHIP TO INSURED

SELF SPOUSE CHILD OTHER

X

9. OTHER HEALTH INSURANCE COVERAGE – Enter Name of Policyholder,

Plan Name, Address and Policy or Medical Assistance Number

BC/BS Camp Hill, PA 11-1111

10. WAS CONDITION RELATED TO

A) PATIENT’S EMPLOYMENT

YES X NO B) AN AUTO ACCIDENT

YES NO

12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE – (Read back before signing)

I Authorize the Release of any Medical Information Necessary to Process this Claim and Request

Payment of Medicare Champus Benefits Either to Myself or the Party Who Accepts Assignment Below

SIGNED Jane Doe Date 1/31/02

13. I Authorize Payment of Medical Benefits to Undersigned

Physician or Supplier for service described below

SIGNED (Insured or Authorized Person)

PHYSICIAN OR SUPPLIER INFORMATION 14. DATE OF

01 / 19 / 02

ILLNESS (FIRST SYMPTOM) OR

INJURY ACCIDENT OR

PREGNANCY (LMP)

15. DATE FIRST CONSULTED

YOU FOR THIS CONDITION

01 / 19 / 02

16. HAS PATIENT EVER HAD SAME OR SIMILAR

SYMPTOMS?

YES X NO

17. DATE PATIENT ABLE TO

RETURN TO WORK

UNDETERMINED

18. DATES OF TOTAL DISABILITY

FROM 1/21/02 THROUGH APPROXIMATELY 6 WKS

DATES OF PARTIAL DISABILITY

FROM THROUGH

19. NAME OF REFERRING PHYSICIAN

Robert Little, MD

20. FOR SERVICES RELATED TO HOSPITALIZATION

GIVE HOSPITALIZATION DATES

ADMITTED DISCHARGED

21. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED (if other than home or office)

ER. Phys Holy Spirit Hospital

22. WAS LABORATORY WORK PERFORMED OUTSIDE

YOUR OFFICE?

YES NO CHARGES

23. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, RELATED DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE TO NUMBERS 1, 2, 3, ETC OR DX CODE

1. 824.0

2.

3.

4.

24. A

DATE OF

SERVICE

B

PLACE

OF

SERVICE

C FULLY DESCRIBE PROCEDURES, MEDICAL SERVICES OR SUPPLIES

FURNISHED FOR EACH DATE GIVEN

D

DIAGNOSIS

CODE

E

CHARGE

F

PROCEDURE CODE

(IDENTIFY)

(EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES)

1/19/02

1/21/02 See attached itemized bills

for complete breakdown

25. SIGNATURE OF PHYSICIAN OR SUPPLIER

(Read back before signing)

SIGNED R Little DATE 1/31/02

27. TOTAL CHARGE 28. AMOUNT

PAID

29. BALANCE

DUE

30. YOUR SOCIAL SECURITY NO. 31. PHYSICIAN’S OR SUPPLIER’S NAME, ADDRESS, ZIP CODE &

TELEPHONE NO. Robert Little, MD 1900 Erford Road Camp Hill, PA 17011 I D NO

32. YOUR PATIENT’S ACCOUNT NO.

JD 204-67-01

33. YOUR EMPLOYER ID NO.

*PLACE OF SERVICE CODES

1-(H)-INPATIENT HOSPITAL 4-(H)-PATIENT’S HOME 7-(NH)-NURSING HOME O-(OL)-OTHER LOCATIONS

2-(OH)-OUTPATIENT HOSPITAL 5-(DAY CARE FACILITY (PSY) 8-(SNF)-SKILLED NURSING FACILITY A-(IL)-INDEPENDENT LABORATORY

3-(O)-DOCTOR’S OFFICE 6-NIGHT CARE FACILITY (PSY) 9-AMBULANCE B-OTHER MEDICAL/SURGICAL FACILITY

APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 6-74

SPECIAL “ON ROUTE” ACCIDENT REPORT FORM MUST BE COMPLETED BY AN AUTHORIZED NEWSPAPER REPRESENTATIVE TO

DETERMINE WHETHER ACCIDENT WAS OR WAS NOT “ON ROUTE”

Date Completed January 31, 2002

1. Complete for ANY accident reported to have happened “ON

ROUTE”. That is, delivering, collecting, soliciting on an

established route, or while on a company approved trip.

2. IMPORTANT: No claim can be paid as “ON ROUTE”

unless this form has been properly completed in detail and signed

by the authorized newspaper representative.

A. Name of Independent Contractor Newspaper Carrier Jane Doe Age 52

B. Address 2309 Market St. Camp Hill, PA 17011 Route No. 241-B

C. What are the boundaries of the route? 900 Block of 9th Street to 1300 Block of 12th St.

D. When does Independent Contractor regularly deliver papers? From 4:30 o’clock A M to 6:00 o’clock A M

E. At what location does Independent Contractor receive papers? At Distribution Center (STREET AND NUMBER OR CORNER)

F. When did this accident happen? Date January 18, 2002 At5:30 o’clock A M

G. Where? 1203 10th St.

H. How far is that from Independent Contractor’s home? 2 miles

I. What was the Independent Contractor doing at the time of the injury? Delivery of papers to subscribers

J. How did the accident happen? Carrier tripped on curb, fell and broke her arm.

K. Name of subscriber called on just before the accident? John Denver

Address? 1206 10th St.

L. How far is this from place where accident happened? 200 feet, next house, across the street.

M. What would have been Independent Contractor’s next call if accident had not happened? 1210 10th St

Address?

N. How far is this from place where accident happened? 200 feet

O. Names and addresses of all persons and witnesses from whom you received the above information. Jane Doe, Carrier of Record, and Robert Little, MD

P. I hereby affirm that on (date) 1/31/02 , I personally investigated

this accident and certify that the above is a complete and accurate statement of the facts and the Independent Contractor

policy-certificate was issued at the time of contracting on 11/22/01 .

the investigation David Smith Title District Sales Manager

“Warning: Any person knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claims

containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act,

which is a crime and subject to criminal and civil penalties.”

LETTER OF RECOMMENDATION Date 1/31/02

I have carefully considered all the facts in connection with this claim and hereby recommend it be paid. Kindly

review claim file and advise if you need any additional information to make payment.

NOTE: Do not sign this Letter of

Recommendation if it was not an

“ON ROUTE” accident.

Signed John Miller Circulation Director Circulation Director or Manager

Name of Newspaper HARRISBURG PATRIOT NEWS

Signature of person making