HomeMy WebLinkAbout000137.tiff accident insurance policy
PHILADELPHIA LIFE INSURANCE COMPANY
(Referred to in this Policy as"We, Us, or Our")
Philadelphia, Pennsylvania
(A Member Company of the National Accident Insurance Group)
Policy Number: SR2788-PBPKA-11
We have issued this policy to the Policyholder (referred to as You, Your or Yours) named in item (1) of Section I,for
the premium paid as shown in item (3) of said section. We will insure persons becoming eligible hereunder
(referred to as Insureds)for the conditions and in the manner described in Section Il, Coverage.
Benefits will be paid only if an Insured sustains:
(1) an accidental bodily injury while this policy is in force; and
(2) such injury directly and independently causes a loss covered by the policy.
GUIDE TO THIS POLICY
Schedule Section I
Coverage Section II
Benefits Section III
Exclusions Section IV
Other Policy Provisions Section V
Section I SCHEDULE
(1) POLICYHOLDER
Name: Weld County Head Start Program
Address: 520 13th Avenue
Greeley, Colorado 80631
(2) POLICY PERIOD
Effective Date:
Expiration Date:
(3) PREMIUM
Premium for the policy shall be as follows:
$1,064.00 for the policy term.
137
SR18B8-1 55.9281
Section I (Continued)
(4) ELIGIBLE PERSONS
Persons in the following Class or Classes are Eligible Persons and shall be Insureds under this Policy:
Class Description of Class
All registered students, ages 4 through 5 years, taking part in your sponsored
and supervised Head Start Program.
(5) COVERAGE BY CLASS
Coverage for each Class of Insureds is described in Section II under the Coverage Code(s) shown below for
such Class:
Class Coverage Code Type of Coverage
C-NHA WHILE PARTICIPATING IN POLICYHOLDER SPONSORED ACTIVITY
If two or more Coverage Codes apply to an Insured due to an injury that happened in one accident, we will
pay Benefits as though only one Coverage Code applied.
(6) BENEFITS BY CLASS
Benefits for each Class of Insureds are described in Section III under the Benefits Code(s) shown below for
such Class:
Class Benefits Code Type of Benefits Maximum Amount of Benefits
B-BB Loss of Life, Limbs&Sight $2,500.00
(Principal Sum)
I B-MCA-94 Medical Expense $2,500.00
Deductible Amount: $25.00
I B-MDA Dental Expense $250.00
Deductible Amount: $25.00
I B-NBA Daily In-Hospital Benefit $30.00 per day
Maximum Time Payable: 60 days
CONVEYANCE ACCIDENT DEATH & DISMEMBERMENT BENEFIT
The Principal Sum Amount applicable to an Insured shall be increased by 100% if injury to such Insured
results in an accidental Loss of Life, Limbs or Sight while:
(a) driving, riding as a passenger in or on, boarding or alighting from, any land or water conveyance except
while driving or serving as a member of the crew of any such conveyance for compensation or hire.
(b) riding solely as a passenger, and not as operator or crew member, in or on, boarding or alighting from
any regularly"Scheduled Airline"flight.
SRI 988-1 Can1.1
Section I (Continued)
DEFINITION
The term "Scheduled Airline" means an airline with a license for civil scheduled air transport issued by the country in
which its aircraft are registered. Such airline must file and publish schedules and fares for regular passenger
service between cities.
(7) AGGREGATE LIMIT
The Aggregate Limit as defined in Section III of the Policy is: $50,000.00 for any one accident.
(8) BENEFICIARY RECORDS
Benefits for loss, if any, as respects accidental death only shall be payable to the beneficiary or beneficiaries
as designated in writing and on file with you. If no beneficiary designation has been made, benefits will be
payable in the following order of preference:
(1) to the Insured's Spouse, if living, otherwise
(2) equally to the Insured's lawful children, if living, otherwise
(3) equally to the Insured's mother and father, if living, otherwise
(4) the Estate of the Insured.
All other benefits are payable to the Insured.
(9) AIRCRAFT OWNED OR OPERATED BY YOU
Exclusion numbers (5) (b) and (c), Section IV shall apply to this policy.
(10) SUBROGATION
If a claim and payment is made within the provisions of this policy We reserve to ourself the right of
subrogation against any negligent party for which injury and payment was made.
We shall bear the expense of any court costs and/or attorney fees relating to the matter of our subrogation
interests but shall not participate in any costs or fees by any attorney engaged by the Insured in any action
for damages initiated by the Insured.
SR1988-1Cont.2
Section II COVERAGE Code C-NHA
WHILE PARTICIPATING IN POLICYHOLDER SPONSORED ACTIVITY
This Coverage applies only to those Insureds who are in a Class to which such Coverage applies as shown in item
(5) of Section I.
DESCRIPTION OF COVERAGE
Subject to all other terms of the policy we will cover injury to the Insured while:
(A) on your premises during regular scheduled hours; and
(B) taking part in the sponsored and supervised activity of:
(1) kindergarten;
(2) pre-school;
(3) nursery school;
(4) day care center; or
(5) head start program.
Travel coverage is limited to:
(A) traveling in a group under your supervision on a field trip sponsored by you; or
(B) traveling directly to or from the Insured's home and your premises.
We will not cover injury to the Insured while:
(1) riding as a passenger or otherwise in any flying device.
SR1988-2NHA 84.5539
Section III BENEFITS Code B-BB
PRINCIPAL SUM
(LOSS OF LIFE, LIMBS OR SIGHT)
These Benefits apply only to those Insureds who are in a Class to which such Benefits apply as shown in item (6) of
Section I.
DESCRIPTION OF BENEFITS
If the Insured's injury results in a loss shown below within one year after the accident causing the loss, we will pay
for:
Loss of Life The Principal Sum
Loss of both Hands or both Feet or sight of both Eyes The Principal Sum
Loss of one Hand and one Foot The Principal Sum
Loss of one Hand or one Foot and sight of one Eye The Principal Sum
Loss of one Arm Three-Quarters The Principal Sum
Loss of one Leg Three-Quarters The Principal Sum
Loss of one Hand or one Foot or sight of one Eye One-Half The Principal Sum
DEFINITIONS
Loss of Hand or Foot means the complete and permanent severance through or above the wrist or ankle joint.
Loss of Sight means the total and permanent loss of entire sight. Such loss correctable by surgery or lenses is not
considered total and permanent.
Loss of Arm or Leg means the complete and permanent severance through or above the elbow or knee joint.
If the Insured suffers more than one loss from any one accident, we will pay only one amount,the largest.
SR1988-3BB 66.4293
Section III BENEFITS Code B-MCA-94
MEDICAL EXPENSE
These Benefits apply only to those Insureds who are in a Class to which such Benefits apply as shown in item (6) of
Section I.
DESCRIPTION OF BENEFITS
If the Insured's injuries result in expenses shown below, we will pay for the"Necessary" medical treatment up to the
"Usual" and "Customary" charge for such expense incurred within fifty-two weeks from the date of the accident.
The first expense must be incurred within thirty days of the date of the accident.
Such expense must be for:
(1) treatment by a"Physician"; or
(2) medical services in a"Hospital"; or
(3) employment of a private Registered Nurse while Hospital confined if ordered by the Insured's Physician; or
(4) x-ray exams; or
(5) the use of a ground ambulance within forty-eight hours of the covered accident.
Such expenses must be in excess of the deductible amount (if any), but not more than the maximum amount
shown in item (6) of Section I.
We will not pay for:
(A) services or treatment given by any person employed or retained by you; or
(B) the repair or replacement or prescriptions of eye glasses or contact lens; or
(C) the repair or replacement of or orthopedic or prosthetic limbs or devices; or
(D) any dental expense; or
(E) experimental procedures; or
(F) cosmetic surgery or procedures; or
(G) hospital room and board charges in excess of the semi-private room rate unless hospitalized in a intensive
care unit.
DEFINITIONS
The term "Necessary" means medical treatment that is vital and required for the treatment of a covered accident.
The term"Usual" charge means the fee regularly charged.
The term "Customary" charge means a charge that does not exceed the general level of charges made by the
providers of the same type of training and experience when furnishing the usual treatment for a similar condition.
The"locality"where the charge is made will also be considered.
The term "Locality" means a county or such greater area as is needed to represent a cross section of providers
giving the type service or supplies for which the charge was made.
SR1988-3MCA-94
Section III BENEFITS Code B-MCA-94
The term "Physician" means a person licensed in the healing arts acting within the scope of his or her license.
The term "Hospital" means an institution which meets all of the following requirements:
(1) It is properly accredited and where required by law, holds a license as a Hospital; and
(2) it operates mainly for the care and treatment of sick or injured persons as inpatients; and
(3) it provides twenty-four hours a day nursing care by Registered Nurses; and
(4) it has a staff of one or more Physicians available at all times; and
(5) it provides organized facilities for diagnosis and surgical procedures; and
(6) it is not primarily a clinic, nursing home or convalescent home or similar place of business; and
(7) it is not mainly a place for treating alcoholics or drug addicts.
With respect to outpatient surgery, or diagnostic testing, an ambulatory surgical center or a clinic will be
considered as a Hospital. Such facility must be properly accredited and where required by law, hold a license
allowing the facility to operate as such.
SR1988-3MCA-94(Cant.1) 54.5565
Section III BENEFITS Code B-MDA
DENTAL EXPENSE
These Benefits apply only to those Insureds who are in a Class to which such Benefits apply as shown in item (6) of
Section I.
DESCRIPTION OF BENEFITS
If the Insured's injuries result in a dental expense shown below, we will pay such expense incurred within fifty-two
weeks from the date of the accident. The first expense must be incurred within thirty days of the date of the
accident.
Such expense must be for:
(1) dental treatment by a"Physician or Dentist"; and
(2) services or supplies to sound natural teeth.
Such expenses must be in excess of the deductible amount (if any), but not more than the maximum amount
shown in item (6) of Section I.
We will not pay for:
(A) services or treatment given by any person employed or retained by you; or
(B) the repair or replacement of:
(1) existing dentures or partial dentures; or
(2) existing braces; or
(3) existing bridges of any kind; or
(4) any other artificial dental restoration.
DEFINITION
The term "Physician or Dentist" means a person licensed in the healing arts acting within the scope of his or her
license.
SR19883MDA
648512
Section III BENEFITS Code B-NBA
DAILY IN HOSPITAL BENEFIT
These Benefits apply only to those Insureds who are in a Class to which such Benefits apply as shown in item (6) of
Section I.
DESCRIPTION OF BENEFITS
If the Insured's injuries result in confinement in a "Hospital", we will pay the daily benefit amount shown in item (6)
of Section I.
Such confinement must be:
(1) prescribed by a"Physician"; and
(2) as a registered bed patient.
This benefit starts on the first day of confinement. We will pay this benefit for as long as the Insured is confined to
the hospital, but for no longer than the maximum number of days shown in item (6) of Section I.
A subsequent period of confinement will be deemed to be the same period of confinement and not subject to a new
elimination period and benefit period unless:
(A) an Insured has resumed his or her full-time job for a continuous period of three months or longer; or
(B) the confinement is for a new injury for which we have not paid benefits under this policy.
DEFINITIONS
The term "Hospital" means an institution which meets all of the following requirement:
(1) It is properly accredited and where required by law, holds a license as a Hospital; and
(2) it operates mainly for the care and treatment of sick or injured persons as inpatients; and
(3) it provides twenty-four hours a day nursing care by Registered Nurses; and
(4) it has a staff of one or more Physicians available at all times; and
(5) it provides organized facilities for diagnosis and surgical procedures; and
(6) it is not primarily a clinic, nursing home or convalescent home or similar place of business; and
(7) it is not mainly a place for treating alcoholics or drug addicts.
An institution operated mainly for the treatment of mental disorders, which meets the definition of a hospital, except
for the lack of surgical facilities, will be deemed to be a hospital.
If a confinement is in a special unit of a hospital used mainly as a nursing, rest or convalescent home will be
deemed to be a confinement in an institution other than a hospital.
The term "Physician" means a person licensed in the healing arts acting within the scope of his or her license.
SR1888.3NBA 56.2140
Section III (Continued)
EXPOSURE AND DISAPPEARANCE
We will pay the appropriate Benefit if the Insured:
(1) is exposed to the elements due to an accident covered by the policy; and
(2) sustains a loss for which a Benefit would otherwise be paid under the policy.
We will presume death due to an injury to the Insured if:
(1) the Insured's body is not found within one year from the date of an aircraft accident in which he or she was a
passenger; and
(2) if the aircraft accident is covered by the policy.
AGGREGATE LIMIT
The most we will pay for all losses due to one accident is the amount shown in item (7) of Section I.
The Aggregate Limit may not be enough to pay the full Benefit to which each Insured who suffers a loss is entitled.
In this event, the Benefit payable to each Insured will be reduced in equal proportion. The proportion will be
determined by dividing the Aggregate Limit by the total of all the Benefits payable without such limit.
SR1888-3Con1. 63.1310
Section IV EXCLUSIONS
We will not pay for any loss as a result of:
(1) suicide, while sane or insane; or intentional self-inflicted injury;
Note: If you reside in Missouri the words"or insane"do not apply.
(2) sickness, disease or bacterial infection of any kind, except:
(a) those for which provisions may have been made in Section III, Benefits; or
(b) those which occur as a result of accidental ingestion; or
(c) pus forming infections which occur through an accidental cut or wound;
(3) war or any act of war,whether war is declared or not;
(4) serving in one of the armed forces of any country or international authority;
Note: If the Insured becomes a member of such armed forces during the policy term, upon receipt of
written notice, we will refund pro rata the unearned premium.
(5) riding as a passenger or otherwise in any flying device:
(a) other than as provided in Section II, Coverage;
(b) owned by You other than as provided in item (9), of Section I;
(c) operated by You other than as provided in item (9), of Section I;
Note: The term "operated by You" shall mean any non-owned aircraft borrowed, leased or rented for
a period of either 10 straight days or 20 days per year.
(d) not having a valid and current Standard Airworthiness Certificate issued by the proper authority;
(e) whose pilot is not properly licensed; or
(f) on a flight which requires a special permit or waiver from the authority having control over civil aviation
even though granted.
Note: A permit which is given to fly over or land on a territory is not a special permit.
(g) being used for other than transportation purposes, such as but not limited to:
racing or endurance tests animal herding
crop dusting or seeding or spraying aerial photography
fire fighting banner towing
exploration experimental tests
pipe or power line inspection skydiving or skywriting
parachuting, except as a life-saving means hunting
(6) hernia, however caused;
(7) the Insured's own felonious act or attempt of such an act; or the taking part in any illegal occupation; or
(8) the Insured being under the influence of any narcotic drug unless taken on the advice of a physician.
SF1988-4D8-94 59.2370
Section V OTHER POLICY PROVISIONS
(1) THE CONTRACT: This policy, application, if any, all endorsements and any attached papers make up the
entire contract. Any change to this policy or waiver of its provisions must be approved by our officer. This
approval must be noted on or attached to this policy. No agent may change or waive any provision in this
policy.
(2) POLICY PERIOD: The policy takes effect on the effective date shown in item (2) of Section I. It will become
effective at 12:01 a.m. at your address shown in item (1) of Section I. The policy will continue in force until
the expiration date shown in item (2) of Section I. The policy may also be terminated in accordance with
item (7) of this section.
(3) PREMIUM: Premiums due for the policy shall be remitted to us as shown in item (3) of Section I.
(4) GRACE PERIOD: There is a 31 day grace period for late payment of each premium after the first one. The
grace period starts on the premium due date. Premium will accrue during this grace period, and you are
liable for such premium. There is no grace period if we advise you in writing that we are not going to renew
the policy. This notice will be given at least 30 days before the premium due date. Our notice in writing will
be mailed or delivered to your last address shown in our records.
(5) EXAMINATION AND AUDIT: We have the rights to examine your records relating to this policy. We may
do this at any time during the policy term. We may also do this within three years after the policy ends.
(6) EFFECTIVE AND TERMINATION DATES OF INDIVIDUAL INSURANCE: If premium for this policy is non-
contributory, insurance for eligible persons as described in item (4) of Section I will take effect on the
effective date of the policy. Persons becoming eligible for this insurance after that date will have their
insurance effective on the date they become eligible.
If a person is absent from active full-time work for health reasons, at the time the insurance would normally
take effect, his or her insurance will be delayed. The insurance will take effect on the date the person returns
to active full-time work.
Insurance for persons insured hereunder shall terminate at 12:01 a.m. on the day immediately following the
first to occur of: 1) the date the person ceases to be an eligible person; or 2) the date you fail to pay, except
for inadvertent error, the required premium.
If premium for this policy is contributory; insurance for eligible persons enrolling in this policy will take effect
on the policy effective date if we have received and approved the enrollment forms for such persons by that
date. Insurance for persons whose enrollment forms are received and approved after that date will have
their insurance effective on the first day of the month following such receipt and approval.
Insurance for such Persons shall terminate at 12:01 a.m. on the next premium due date immediately
following the first to occur of: 1) the date the person ceases to be an eligible person; 2) the date the person
withdraws premium contribution authority; or 3) the date you fail to pay, except for inadvertent error, the
required premium.
Any claim that occurs prior to this termination will not be affected.
(7) POLICY TERMINATION: You may cancel this policy at any time after the first premium term by giving us
written notice in advance of such cancellation. The effective date of termination will be the date we receive
such notice, or a later date if shown in the notice. We may cancel this policy at any time by sending a
written notice to you at the address shown in our records. The effective date of termination will be at least 30
days later than the date of our written notice.
Any premium owed to us, in the event of you or us cancelling, must be promptly paid. If you cancel, we will
refund the unearned premium, if any, based on the normal short rate procedures. If we cancel, we will
refund the unearned premium, if any, on a pro rata basis.
SR1988-5(CO) 56.6839
(8) NOTICE OF CLAIM: Written notice of claim must be given to us within 20 days after a covered loss occurs
or begins. If such notice cannot be given during such time, then it must be done as soon as reasonably
possible. The notice must include your name, the Insured 's name and policy number. It should be sent to
us in care of: National Accident Insurance Underwriters Inc., 85 West Algonquin Road, Arlington Heights,
Illinois 60005, or to one of our agents.
(9) CLAIM FORMS: When we receive written notice of claim, we will send the claimant forms for filing proof of
loss within 15 days. If we don't, written proof of loss will be met by the Insured or beneficiary by sending us
written proof as described below.
(10) WRITTEN PROOF OF LOSS: Proof of loss must describe the incident, extent and the type of loss. For
death claims, proof of loss means certified copies of the death certificate, autopsy if performed, Coroner,
Medical Examiner or Justice of the Peace reports. Police Motor Vehicle Accident Report or Police Incident
Report, if applicable, are also proof of loss documents.
Written proof of loss must be sent to us at the address shown above, or to one of our agents. If the claim is
for a continuing loss for which we make periodic payments, the claimant must give us written proof of loss
within 90 days after the end of each period that benefits are payable.
For any other loss, written proof must be given to us within 90 days after the date of loss. If proof of loss
cannot be given in that time, such proof of loss must be given as soon as reasonably possible. Except in the
absence of legal capacity, the claimant must give written proof within one year of the time otherwise
required.
(11) TIME OF PAYMENT OF CLAIMS: We will pay any benefits due once we receive written proof of loss.
Benefits that provide for periodic payment will be paid monthly.
(12) PAYMENT OF CLAIMS: We will pay death benefits to the beneficiary designated by the Insured and on file
with the holder of beneficiary records. If a beneficiary has not been designated, death benefits will be paid
to the estate of the Insured. All other benefits will be paid to the Insured except for medical benefits (if
applicable). These may be paid directly to the provider of medical services.
Any payments we make in good faith will end our liability to the extent of the payment.
(13) PHYSICAL EXAMINATION AND AUTOPSY: We have the right to have the Insured examined by a
physician of our choice. This may be done as often as reasonably necessary while a claim is pending or
while we are paying benefits. We may also have an autopsy made unless the law forbids it. We will pay the
cost of both the exam and autopsy.
(14) LEGAL ACTIONS: No legal action may be brought to recover on this policy within 60 days after written
proof of loss has been given as required by the policy. No such action may be brought after 3 years from
the time written proof of loss is required to be given.
(15) BENEFICIARY DESIGNATION AND CHANGE: The Insured may choose one or more beneficiaries. We
will furnish forms for this use. Such forms shall be filed with the holder of the beneficiary records as shown
in item (8) of Section I. The Insured may change beneficiaries at any time. The beneficiary's consent is not
required unless an irrevocable beneficiary has been named. The change will be effective only upon receipt
by the holder and ft will take effect on the date the Insured signs it. Any payment made by us in good faith
prior to our receipt of any beneficiary change will end our liability to the extent of such payment.
(16) ASSIGNMENT: An Insured may assign his or her interest under this policy. In the case of an irrevocable
beneficiary, that person must give written consent. No assignment will be binding on us unless it is in writing
and a copy sent to us. We accept no responsibility for the validity of an assignment.
(17) CERTIFICATE OF INSURANCE: We shall provide you with.certificates to give to each Insured where
required by law. The certificate will describe the Insured's coverage and state to whom we will pay benefits.
The certificate is not a part of the policy.
SR1988.5Cont.1 80.8078
(18) POLICYHOLDER'S RECORDS: You will keep records of the insurance on each Insured including persons
who have cancelled.
(19) WORKERS' COMPENSATION: This policy is not a substitute for the Workers' Compensation Law
requirement.
(20) CONFORMITY WITH STATE STATUTES: Any provision of this policy which, on its effective date, is in
conflict with the laws of the state where the policy is issued, is amended to meet those laws.
•
Signed by us as of the policy effective date. This policy is not binding upon us unless it is approved by National
Accident Ind Underwriters, 4 /
Secretary President
Approv,,,. ir(ed:
die .
\ goliviez
National Accident Insurance
Underwriters, Inc.
SR1988-5Cont2 54.4221
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