Form X:D. XVII ACCIDENT AND HEALTH POLICY This Policy provides for loss of Life, Limb, Sight and Time, caused by accidental bodily injuries effected through external violence, and for disability caused by disease, to the extent herein provided. THE INSURANCE COMPANY Does Hereby Insure under classification.. by occupation a against loss resulting from Bodily Injuries, effected directly and independently of all other causes, through External, Violent and Accidental means (Suicide, sane or insane is not covered), and against disability by Disease, as specified in the following Schedules, respectively, subject to the provisions and límitations hereinafter contained. Part A Schedule of Indemnities Accident Insurance The Principal Sum of this Policy is $... Death, Dismemberment and Loss of Sight-Single Indemnity If such injuries shall wholly and continuously disable the Insured from the date of accident from performing any and every kind of duty per taining to his occupation, and during the period of such continuous disability, but within two hundred weeks from date of accident, shall result independently and exclusively of all other causes in any one of the losses enumerated in this part, or within ninety days from the date of the accident, irrespective of total disability, result in like manner in any one of such losses, the Company will pay the sum set opposite such loss and in addition weekly indemnity as provided in Part B to the date of death, dismemberment, or loss of sight; but only one of the amounts so speci. fied and the additional weekly indemnity will be paid for injuries resulting from one accident. Loss shall mean, with regard to hands and feet, dismemberment by severance at or above wrist or ankle joints; with regard to eyes, entire and irrecoverable loss of sight; with regard to thumb and index finger, severance at or above meta. carpo-phalangeal joints. The Payment in any such case shall and this Policy. Or, in the event of the loss of both hands, or both feet, or the sight of both eyes, covered and defined as above, if the Insured shall so elect in writing, the Company will pay in lieu of the specific indemnity enumerated above, weekly indemnity at the rate prescribed in part B for total disability so long as the Insured shall live. Instalment Option to Beneficiary In case of valid claim for death under this Policy, the Beneficiary may elect to have it paid in monthly instalments as follows, for each $1,000: First instalment to be paid immediately after receipt of due proof of claim. 9.86 60 Monthly Instalments Certain of $18.19 7.14 Upon the written request of the Beneficiary at any time before all of the instalments elected hereunder shall have been paid, or upon the like request of her executor or administrator if she shall die before receiving all of such instalments, the then present value of the remainder thereof computed at three and one-hall per cent. interest will be paid in one sum to the Beneficiary or to her executor or administrator, as the case may be, Part B. Total Loss of Time Partial Loss of Time Part C. Total and Partial Disability—Single Indemnity Or, if such injuries, independently and exclusively of all other causes, shall wholly and continuously disable the In. Or, if such injuries, independently and exclusively of all other causes, shall wholly and continuously disable the Double Indemnity If such injuries are sustained (1) while a passenger in or on a public conveyance provided by a common carrier for passenger service (Includ. ing the platform, steps or running-board of railway or street railway cars); or (2) while a passenger in a passenger elevator (excluding elevators in mines); or are caused (3) by the burning of a building provided the Insured is therein at the commencement of the fire; or by the collapse of the outer walls of a building while the Insured is therein; or, (4) by a stroke of lightning; or, (5) by the explosion of a steam boiler; or, (6) by a cyclone or by a tornado; the Company will pay Double the amount otherwise payable under Part A or B of this Policy. The Insured, if he so elect in writing within twenty days from date of accident, may take, in lieu of the weekly indemnity hereinbefore pro vided for total and partial disability, indemnity in one sum, according to the following Schedule, if the injury is one set forth in such Schedule, but not more than one Elective benefit shall be paid for injuries resulting from one accident. When the Insured is entitled to double indemnity the Elective indemnity shall be doubled in like manner. XVII-Continued ACCIDENT AND HEALTH POLICY Schedule of Elective Benefits If the single weekly indemnity for total loss of time payable under this Policy is $50.00, the amounts named below shall be payable; if such weekly indemnity is greater or less than $50.00, the amounts to be paid shall be increased or reduced proportionately. Part B. Temporary Permanent Schedule of Indemnities-Health Insurance (1) For the period of continuous disability during which the Insured shall, independently of all other causes, be wholly disabled (2) If the Insured shall suffer the entire and irrecoverable loss of the use of both hands or both feet, or of one hand and one The Payment for Permanent Disability shall end this Policy. No payment shall be made for disability resulting from any disease for which the Insured is not treated by a physician or from disease beginning within fifteen days from noon of the date of this Policy. Part F. Surgical Benefits-Accident and Health Insurance If an operation named in the Schedule of Operations which forms a part of this Policy shall be performed by a surgeon on account of a bodily injury or disease covered by this Policy and within ninety days from the date of accident or commencement of such disease, the Company will pay the surgical benefit specified in the Schedule for such operation in addition to any other indemnity to which the Insured may be entitled. If more than one such operation shall be performed on account of injury sustained in one accident or on account of one illness the Insured shall receive the largest surgical benefit specified in the Schedule for any one of the operations so performed. If an accidental bodily injury shall be sustained which shall not result in death or other disability, or necessitate an operation named in the Schedule, but which shall require surgical treatment the Company will pay the amount actually expended for such treatment, but not exceeding the amount of the single indemnity hereunder for total loss of time for one week. Part a. Hospital Indemnity-Accident and Health Insurance If on account of a bodily injury or illness for which weekly indemnity is payable under this Policy, the Insured shall be removed to a hospital within ninety days from the date of accident, or commencement of disability by disease, the Company will pay 50 Per Cent. additional single weekly indemnity for the period during which he shall be a patient resident in the hospital but not exceeding twenty consecutive weeks. Part H. Identification and Registration If the Insured by reason of injury or illness shall be physically unable to communicate with friends, the Company, upon receipt of a telegram or other message giving the number of this Policy, will immediately transmit to his relatives or friends any information respecting him, and will defray all expenses necessary to put the Insured in the care of friends, provided such expense shall not exceed the sum of One Hundred Dollars. Standard Provisions 1. This Policy includes the endorsements and attached papers, if any, and contains the entire contract of insurance except as it may be modified by the Company's classification of risks and premium rates in the event that the Insured is injured after having changed his occupation to one classified by the Company as more hazardous than that stated in the Policy, or while he is doing any act or thing pertaining to any occupation so classified, except ordinary duties about his residence or while engaged in recreation, in which event the Company will pay only such portion of the indemnities provided in the Policy as the premium paid would have purchased at the rate but within the limits so fixed by the Company for such more hazardous occupation. If the law of the State in which the Insured resides at the time this Policy is issued requires that prior to its issue a statement of the premium rates and classification of risks pertaining to it shall be filed with the state official having supervision of insurance in such state, then the premium rates and classif cation of risks mentioned in this Policy shall mean only such as have been last filed by the Company in accordance with such law, but if such filing is not required by such law then they shall mean the Company's premium rates and classification of risks last made effective by it in such state prior to the occurrence of the loss for which the Company is liable. 2. No statement made by the applicant for insurance not included herein shall avoid the Policy or be used in any legal proceeding hereunder No agent has authority to change this Policy or to waive any of its provisions. No change in this Policy shall be valid unless approved by an executive officer of the Company and such approval be endorsed hereon. 3. If default be made in the payment of the agreed premium for this Policy, the subsequent acceptance of a premium by the Company or by any of its duly authorized agents shall reinstate the Policy but only to cover accidental injury thereafter sustained and such sickness as may begin more than ten days after the date of such acceptance. 4. Written notice of injury or of sickness on which claim may be based must be given to the Company within twenty days after the date of the accident causing such injury or within ten days after the commencement of disability from such sickness. In event of accidental death immediate notice thereof must be given to the Company. 5. Such notice given by or in behalf of the Insured or Beneficiary, as the case may be, to the Company at A or to any authorized agent of the Company, with particulars sufficient to identify the Insured, shall be deemed to be notice to the Company Failure to give notice within the time provided in this Policy shall not invalidate any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible. 6. The Company upon receipt of such notice, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not so furnished within fifteen days after the receipt of such notice. the claimant shall be deemed to have complied with the requirements of this Policy as to proof of loss upon submitting within the time fixed in the Policy for filing proofs of loss, written proof covering the occurrence, character and extent of the loss for which claim is made. 7. Affirmative proof of loss must be furnished to the Company at its said office in case of claim for loss of time from disability within ninety days after the termination of the period for which the Company is liable, and in case of claim for any other loss, within ninety days after the date of such loss. 8. The Company shall have the right and opportunity to examine the person of the Insured when and so often as it may reasonably require during the pendency of claim hereunder, and also the right and opportunity to make an autopsy in case of death where it is not forbidden by law. 9. All indemnities provided in this Policy for loss other than that of time on account of disability will be paid immediately after receipt of due proof 10. Upon request of the Insured and subject to due proof of loss all accrued indemnity for loss of time on account of disability will be paid at the expiration of each four weeks during the continuance of the period for which the Company is liable, and any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of due proof. 11. Indemnity for loss of life of the Insured is payable to the Beneficiary if surviving the Insured, and otherwise to the estate of the Insured. All other indemnities of this Policy are payable to the Insured. 12. If the Insured shall at any time change his occupation to one classified by the Company as less hazardous than that stated in the Policy, the Company, upon written request of the Insured and surrender of the Policy, will cancel the same and will return to the Insured the unearned premium. 13. Consent of the Beneficiary shall not be requisite to surrender or assignment of this Policy, or to change of beneficiary, or to any other changes in the Policy. 14. No action at law or in equity shall be brought to recover on this Policy prior to the expiration of sixty days after proof of loss has been filed in accordance with the requirements of this Policy, nor shall such action be brought at all unless brought within two years from the expiration of the time within which proof of loss is required by the Policy. 15. If any time limitation of this Policy with respect to giving notice of claim or furnishing proof of loss is less than that permitted by the law of the state in which the Insured resides at the time this Policy is issued, such limitation is hereby extended to agree with the minimum period permitted by such law. 16. The Company may cancel this Policy at any time by written notice delivered to the Insured or mailed to his last address as shown by the records of the Company, together with cash or the Company's check for the unearned portion of the premiums actually paid by the Insured, and such cancelation shall be without prejudice to any claim originating prior thereto. Additional Provisions (a.) The insurance under Parts A to D inclusive, shall not cover accident, injury, disability, death or other loss caused directly or indirectly, wholly or partly, by bodily or mental infirmity, ptomaines, bacterial infections (except pyogenic infections which shall occur with and through an accidental cut or wound), or by any other kind of disease; nor shall it cover any injury, fatal or non-fatal, caused directly or indirectly by war or by any act of war, or sustained by the Insured while participating in or in consequence of having participated in aeronautics; nor shall it cover the Insured while in military or naval service in time of war. (b.) The insurance under Part E shall not cover disease contracted, or sickness or disability sustained, in the tropics or in any part of Alaska or the British Possessions in America, north of the sixtieth degree of north latitude; nor shall it cover disability by disease while engaged in military or naval service, nor shall it cover disability for any period for which the Insured has either made claim or may become entitled to indemnity for or on account of injuries by accidental violence; nor shall it cover disability unless the disease is contracted, and the disability begins while the Policy is in force. (c.) A copy of any assignment shall be given within thirty (30) days to the Company which shall not be responsible for its validity. (d.) The copy of the application endorsed hereon is hereby made a part of this contract which is made subject thereto. No provision of the charter, constitution or by-laws of the Company shall avoid the insurance hereunder or be used in evidence or in defense of any claim arising under this Policy dollars, for the term of (e.) This Policy is issued in consideration of the premium off. months, to commence on the day this Policy is dated against acidental bodily injuries, and for the term of. days to commence on the fifteenth day after the day this Policy is dated against disability by disease and beginning and ending in each case at twelve o'clock noon, standard time of the place where Insured resides, but it may be renewed with the consent of the Company, from term to term of. months each, by the payment of the aforesaid premium in advance until the Insured shall be fifty-one years of age. If the Policy shall be renewed thereafter, the renewal premium shall dollars. be In Witness Whereof Tus day of INSURANCE COMPANY has caused this Policy to be signed by its President and a Secretary, and dated this 19, but the same shall not be binding upon the Company until countersigned by a duly authorized Do your average weekly earnings exceed the aggregate single weekly indemnity payable under this Policy and all other similar policies now carried by you? What life, accident or health insurance have you in this Company?. Have you ever made application for life, accident or health insurance upon which you have not been notified of the action thereon?.. Has any life, accident or health policy issued to you been canceled or has any renewal thereof been refused, by this or any other company or association? P. Have you within the past five years had medical or surgical advice or treatment or any departures from good health? If so, state when and what, and duration (Mouth-Year) (Nature of Allment) (Duration of Aliment) R. S. Have you ever had, or ever been advised to have, an operation?.. (If Answer to "Yes", give fall particular) Have you been exposed during the last ten days to any contagious or infectious disease?. Do you agree that the falsity of any answer in this application for a Policy shall bar the right to recover thereunder if such answer is made with intent to deceive or materially affects either the acceptance of the risk or the hazard assumed by the Company?__ Policy applied for this. day of. 19-- *If no benefit in Policy for loss of life write "Nə death benefit” in section H. Signature of Applicant. XVII-Continued Schedule of Operations-Surgical Benefits If the single weekly indemnity for total loss of time payable under this Policy is $50.00, the amounts named below shall be payable. If such weekly indemnity is greater or less than $50.00 the amounts to be paid shall be increased or reduced proportionately. ABSCESS. Incision ABDOMEN. Cutting into Abdominal Cavity for diagnosis or $10 GOITRE. Cutting operation for permanent cure $150 ANEURISM. Operation for tying of Artery APPENDICITIS. Abdomen. BONE. Injuries to or disease of. Removal of diseased portion of bone CANCER OF LIP. Removal of, by cutting operation CARBUNCLE. Incision CHEST. Cutting into thoracic cavity for diagnosis or treat ment of organs therein DISLOCATION. Reduction of Hip or Knee Shoulder, Elbow, or Ankle Wrist or Lower Jaw Thumb Fistula in Ano Malignant Stricture SKULL Cutting into cranial cavity for permanent cure of. 100 SPINE OR SPINAL CORD. Operation with removal of frac 200 STRICTURE CESOPHAGUS. Cutting operation (external) 200 STONE IN BLADDER. Removal of, by cutting or crushing 150 TAPPING OF. Abdomen Bladder Chest Ear Drum Hydrocele Forearm 50 Wrist 50 4 1 XVIII ACCIDENT AND HEALTH POLICY This policy provides indemnity for loss of life or time through accidental means, THE INSURANCE COMPANY (HEREIN CALLED COMPANY) HEREBY INSURES and described in the Application), subject to all provisions and limitations herein contained: (herein called Insured Against loss of life resulting directly and independently of all other causes, a bodily injury effected during the term of this policy solely through accidental means; and Against disability commencing while this policy is in force and resulting from bodily injury effected through accidental means; and against disability commencing while this politis in card resulting from sickness; such disability, in both cases, to be such as will result in continuous total loss of busmass time as follows: SPECIMEN Life Part A The Company will pay should loss of life as defined above res within hundred and twenty days from date of the accident. Disability Dollars Part B. The Company will demnity at the rate of Dollars per month during the continuance of disability as defined above until such time as the Insured engages in a gainful occupation, provided, however; that no indemnity shall be paid under this Part B or under Parts C, D or E, for the of any period of disability. Loss of Both Hands, Both Feet, Hand and Foot or the Sight of Both Eyes Part C. Should the Insured suffer, as a direct result of such injury or such sickness, the loss of both entire hands by complete severance at or above the wrists, or the loss of both entire feet by complete severance at or above the ankles, or the loss of one entire hand by complete severance at or above the wrist and one entire foot by complete severance at or above the ankle, or the irrecoverable loss of the entire sight of both eyes, he shall be deemed to have sustained a permanent disability resulting in continuous total loss of his business time and the Company will pay indemnity at the rate per month specified in Part B as long as he shall live, or; Loss of One Hand or One Foot Part D. Should the Insured suffer, as the direct result of such injury or such sickness, the loss of one entire hand by complete severance at or above the wrist, or the loss of one entire foot by complete severance at or above the ankle, the Com pany will pay indemnity at the rate per month specified in Part B for the period for which such loss causes disability as defined above, and at the termination of such disability will consider such loss to have caused a permanent disability of 25%, and will pay the lasured, as long as he shall live, monthly indemnity at the rate of 25% of the amount specified in Part B, or; Loss of the Sight of One Eye Part E Should the Insured suffer, as the direct result of such injury or such sickness, the irrecoverable loss of the entire sight of one eye, the Company will pay indemnity at the rate per month specified in Part B for the period for which such loss causes disability as defined above, and at the termination of such disability will consider such loss to have caused a permanent disability of 10%, and will pay the Insured, as long as he shall live, monthly indemnity at the rate of 10% of the amount specified in Part B. *No indemnity is payable under this policy for the specified first part of any period of disability. Renewable through age 65. |