THIS IS AN ACCIDENTAL DEATH AND REPATRIATION ONLY POLICY

Transcription

1 COMMERCIAL ALLIANCE INSURANCE COMPANY 415 LOCKHAVEN DRIVE HOUSTON, TEXAS POLICY OF INSURANCE CAIC/A&H00004 REPATRIATION INSURANCE THIS IS AN ACCIDENTAL DEATH AND REPATRIATION ONLY POLICY CAIC/A&H

2 IMPORTANT NOTICE To obtain information or make a complaint: AVISO IMPORTANTE Para obtener información o para someter una queja: You may call Commercial Alliance Insurance Company toll-free number for information or to make a complaint at: Usted puede llamar al número gratuito de la compañía Commercial Alliance Insurance Company al: You may call also write to Commercial Alliance Insurance Company at: Commercial Alliance Insurance Company 415 Lockhaven Drive Houston, Texas También puede escribir a Commercial Alliance Insurance Company a: Commercial Alliance Insurance Company 415 Lockhaven Drive Houston, Texas You may contact the Texas Department of Insurance to obtain information on any companies, coverage s, rights or complaints at: Puede comunicarse al Departamento de Seguros de Texas para obtener información acerca de compañías, coberturas, derechos o quejas al: You may write the Texas Department of Insurance at: Puede escribir al Departamento de Seguros de Texas: P.O. Box Austin, Texas Fax # LIFEHEALTH@tdi.state.tx.us Web: P.O. Box Austin, Texas Fax # LIFEHEALTH@tdi.state.tx.us Web: PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact the agent or the company first. If the dispute is not resolved, you may contact the Texas Department or Insurance. DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o un reclamo, debe comunicarse primero con la compañía de seguros. Si no le resuelven su situación, entonces comuníquese con el Departamento de Seguros de Texas (TDI). ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document. GUARDE ESTE AVISO CON SU PÓLIZA: Este aviso es solo para facilitarle información pero no se convierte como parte del documento adjunto.

3 COMMERCIAL ALLIANCE INSURANCE COMPANY Home Office: Houston, Texas (Herein Called the Company) YOU ARE COVERED FOR REPATRIATION FOR ACCIDENTAL DEATH ONLY. THE POLICY DOES NOT PAY BENEFITS FOR LOSS CAUSED BY SICKNESS. READ YOUR POLICY WITH CARE. TERMS AND CONDITIONS OF COVERAGE Benefits specified below will be paid while the Policy is in force and the Covered Person suffers loss by death, resulting directly from accidental bodily injury ( such injury ) received as a result of an accident. The accident itself, and/or the accidental injuries to the Covered Person, must have occurred within the U.S.A. The accident must have occurred within the dates this Policy is in effect. If, within one (1) year from the date of accident itself, the bodily injuries received in such accident results in death, the Company will pay the Policy benefits. If a Covered Person lives more than a year from the date he/she was originally injured, the death is not considered accidental, per the terms and definitions of this Policy. I. Loss means Repatriation Services from the United States of America to Mexico or Central America and/or within the United States of America. The accidental death of the Covered Person must have occurred in the U.S.A. for this Policy to provide benefits. 1. Repatriation of Body or Mortal Remains (Mexico or Central America) In the event of the accidental death of COVERED PERSON in the United States of America, COMPANY will coordinate the transportation of the body or mortal remains of COVERED PERSON to the designated place of burial or home town in Mexico or Central America. COMPANY will request and pay the corresponding transfer permits. The payment of any related expenses will be covered by COMPANY. All bodies will be embalmed if required by either the shipping or receiving country. 2. Payment of Transactions and Negotiations In the event of accidental death of COVERED PERSON in the United States of America COMPANY will carry out, by available and reasonable means, the necessary transactions to transport and repatriate the body or mortal remains of COVERED PERSON to either the Republic of México and/or a designated location in the U.S.A. This service includes: Certificate of Death (with original stamps and signatures). In the event of accidental death, notification affidavit to the authorities and if an investigation is pending or in progress corresponding documentation. Necessary sanitary permits. Embalming and Embalming Certificate if required by health authorities and health regulations in the country of origin or destination. Shipment casket. Apostilles and notarizations. Special packaging for transportation (if required by embassy). Payment of applicable duties and fees to complete transport. 3. Application Part of Policy The insurer, Commercial Alliance Insurance Company, relies upon the information and representations contained in the Application, particularly as to the Beneficiaries whom will decide the place to ship the body/remains of the COVERED PERSON. 3

4 II. Coordination of the Funerary Services in designated place or hometown. 1. If Mexico or Central America is the final and chosen designation to take the body/remains of the COVERED PERSON, the Company will provide: a. Legal advice regarding accreditation of death to Authorities: The COMPANY, through one of its network providers, will provide legal advice to surviving relatives regarding the necessary procedures or transactions to notify the authorities of the demise of COVERED PERSON in the event of accidental death. b. Transportation of the body or mortal remains of the COVERED PERSON to the specific location chosen by Beneficiary: The COMPANY, through one of its network providers, will arrange and assume the costs of local transportation of the body or mortal remains of COVERED PERSON to a funeral home and/or place of a wake or viewing. The COMPANY, through one of its network providers, will obtain the corresponding permits for such local transportation, if needed. c. Transportation of the body or mortal remains of the COVERED PERSON to the cemetery or crematory: If the BENEFICIARY of the deceased COVERED PERSON asks for this service, COMPANY will arrange and assume the costs of the transfer to the cemetery or crematory. Also, COMPANY will obtain necessary permits and assume corresponding fees. The COMPANY reserves the right to coordinate this with the entity providing the Funerary Services, where applicable. 2. If the U.S.A. is the final and chosen designation to take the body/remains of the COVERED PERSON, the Company will provide the same basic services as set forth in Section II 1. above. III. Funerary Services Not Covered: All FUNERARY SERVICES are the responsibility of the BENEFICIARY and the surviving relatives of the deceased COVERED PERSON. FUNERAL SERVICES ARE NOT COVERED BY THIS POLICY. Specifically, items not covered by this Policy include: An upgraded casket other than the one the body is shipped in. Makeup application to corpse (cosmetic arrangement) in Mexico or Central America and/or at the place the funeral is held. Cost of Funeral Chapel or Funerary Parlor and related services and expenses incidental to a wake/visitation in Mexico or Central America and/or where the body is viewed. Charges for the actual funeral service in the town/area where the COVERED PERSON is buried. Expenses incurred for the cemetery, and/or cemetery site, plot or headstone. This includes any ongoing fees at a cemetery for upkeep or maintenance. IV. Exception of Service. 1. Services herein described will not be provided in the following cases: When the COVERED PERSON s death is determined to be from natural causes. When the COVERED PERSON s premium has not been paid or coverage has been cancelled by the COVERED PERSON. If the COVERED PERSON s accident or accidental death occurs somewhere other than within the U.S.A. V. Characteristics of the Service. Coordination of all services described herein will be for the repatriation of the body or mortal remains of the COVERED PERSON from the United States of America and to the Republic of Mexico or Central America and/or within the U.S.A., 24 (twenty four) hours a day, 365 (three hundred and sixty five) days a year. VI. Controversy. In the event of controversy regarding the cause of death of the COVERED PERSON, in relation to the Exception of Service, an action at law or in equity may not be brought to recover on this Policy before the sixty-first (61 st ) day after the date written proof of loss has been provided in accordance with the requirements of this Policy. An action at law or in equity may not be brought after the expiration of three (3) years after the time written proof of loss is required to be provided. 4

5 VII. No Coverage for Named Insured s Property. This Policy provides no coverage for any personal property or personal items of the COVERED PERSON. Beneficiaries should make separate arrangements to secure named insured s personal items of value upon learning of such accident death. VIII. Accidental Death and Claim Notification Post Funeral. If the Beneficiaries first make a claim which is covered per the terms of this Policy, after the funeral of the COVERED PERSON and the repatriation feature of this Policy is not used, the Company will pay the Beneficiaries the Policy Limits. If this event occurs, the COMPANY has no other obligations or duties under this Policy. REPATRIATION & DEATH BENEFIT LOSS Repatriation & Death BENEFIT Four options are offered: Option 1 Option 2 Option 3 Option 4 $6, US DOLLARS $10, US DOLLARS $16, US DOLLARS $20, US DOLLARS DEFINITIONS We, Us, Our, or The Company means Commercial Alliance Insurance Company Covered Person means the named Insured in the Application. Beneficiary means the Covered Person s Beneficiary set forth in the Policy Application. It will be deemed plural if more than one Beneficiary is listed on the Application. The first Beneficiary listed on the Application has sole authority to designate the location as to where the Covered Person s body will be shipped. Repatriation means if a person dies in the U.S.A., they are repatriated when their body is returned to Mexico or Central America and/or designated place within the U.S.A. Repatriation insurance is used to prepare the body and the body s transportation expenses to the return of the Covered Person s body/remains to Mexico or Central America and/or within the U.S.A. Accident means a sudden forceful unexpected and unintended event causing physical injuries which are the primary and principal cause of the death of the Covered Person. Natural Causes and or Disease Process means death caused due to either an ongoing physical process (for example, diabetes, cancer or like deteriorating illness) or solely internal cause(s) (for example, heart or any organ failure including stroke). A death by natural causes and/or disease process is not a death caused directly due to a sudden and unexpected external physical blow or injury to the decedent s body. 5

6 Accidental Death means the death of the Covered Person, while in the USA, caused directly by accidental bodily injuries. The accidental bodily injury or injuries must be the primary cause of death to the Covered Person as set forth in the official Death Certificate. To be an accidental death, The Covered Person must die as a direct result of the injuries received within one (1) year from the date of such accident. Solely for purposes of illustration or example, an accidental death, for the purposes of this Policy, can be any of the following: Automobile, truck or motorcycle collisions. The Covered Person can be a driver or an occupant in, or a pedestrian struck by such types of motorized vehicles. An accidental fall caused/causing bodily injuries and subsequent accidental death. Accidental death by gunshot, but only if the Covered Person was a random victim of such event and/or criminal act. Accidental death of the named Covered Person if the death is caused in the course of the insured s work or employment. EXCLUSIONS No benefits will be paid for death of the Covered Person resulting from any of the following: 1. Suicide, attempted suicide or intentionally self-inflicted injuries, causing death whether the Covered Person is sane or insane at the time of such events; 2. Declared or undeclared war or act of war; 3. Injury or death caused by intentional or unintentional armed conflict; 4. Riding or driving in any kind of organized race or racing event; 5. Participating in a riot; commission of or attempt to commit a felony or assault by the covered person; 6. Sickness or disease or medical or surgical treatment of sickness or disease including diagnosis, except when due to injury caused by a covered accident; 7. Bacterial infections except when caused by an accident or medical treatment of an accidental injury; 8. An accident occurring while the Covered Person is serving in any Armed Forces; 9. Travel or flight in, or getting in or out of: an aircraft being used for test or experiment; a military aircraft and/or an aircraft the Covered Person is flying, is learning to fly or is part of the crew of the aircraft. 10. Any disappearance or alleged disappearance of the Named Insured where the Covered Person s body is not found. 11. Natural causes and/or the result of a disease process. SINGLE TERM NON RENEWABLE POLICY NO COVERAGE AT AGE 70 OR MORE This Policy is not renewable. There is no coverage once the Covered Person reaches the age 70. 6

7 COMMON CARRIER BENEFIT We will pay this benefit if: 1. Covered Person is injured in an accident which happens: a. while he or she is covered by the Policy; and b. on any common carrier; and 2. such Covered Person is not a pilot, crewmember or a non fare-paying passenger; and 3. such Covered Person dies or is injured as a direct result and from no other cause within one (1) year from the date of the accident. 7

8 GENERAL PROVISIONS Entire Contract Changes: The Policy with the application[s], endorsements, riders, and attached papers is the entire contract between the Policyholder and the Company. In the absence of fraud, statements made by the Policyholder or by a Covered Person are deemed representatives and not warranties. No such statement will be used in a contest unless it is contained in a written application. No change in the Policy will be valid until approved by the Company. This approval must be endorsed on or attached to the Policy. No agent may change the Policy or waive any of its provisions. Legal Actions: No one may sue for benefits less than sixty (60) days after due proof of loss is submitted, not more than three (3) years after the date claim forms are due. Conformity with State Law: Conformity with State statutes of the U.S.A. only. Any provision of this Policy that, on its effective date, conflicts with the statutes of the state in which the Covered Person resides on the effective date, is by this clause effectively admitted to conform to the minimum requirements of that state s statutes. Examination of the Policy: A copy of the Policy shall be available for inspection by Covered Person during business hours at the Company s office. Misstatement of Facts: If relevant facts about a Covered Person are not correct: 1. a fair adjustment of premiums can be made at the discretion of the Company. 2. and/or the true facts will decide whether and for what amount insurance is valid. Policy of Insurance: The Company will issue to the Policyholder a policy of insurance for each Covered Person covered by the Policy. The Policy will list the benefits, conditions, and limits of the Policy. It will state to whom the benefits will be paid. 30 Day Right to Examine Policy: If a Covered Person does not like his or her Policy, for any reason, he or she must return it to the Company not more than thirty (30) days after he or she receives it. The Company will return any premium that he or she has paid. In this event, the Policy will be VOID, as if it had never been issued. PAYMENT AND NOTICE OF CLAIMS NOTICE Upon Beneficiary s Notice of the accidental death of Covered Person, they shall call to report the death and make a claim. Claim Procedures: Notice of Claim: 8

9 Time is important, and Beneficiary should notify the Company, as soon as possible, of the Covered Person s death. Upon the death of the Covered Person, the Company should receive written notice as soon after that as is reasonably possible. This notice should state the Policy and/or policy number, the Covered Person s name and date and alleged cause of death, if known. This notice should be sent to the Company at the address shown on this Policy or to an agent authorized by the Company. The Company will send the Beneficiary claim forms and immediately seek a Death Certificate to aid in determine the cause of the Covered Person s death. Physical Examination and Autopsy: At the Company s expense, the Company may have the deceased Covered Person s body examined as often as reasonably necessary while a claim is pending. The Company may also request an autopsy in case of death where it is not forbidden by law. An autopsy could assist in determine the cause of death. Any costs of an autopsy required by the Company are solely the responsibility of the Company. Right to Have Copy of Death Certificate: The Company has the right to have a copy of the official Death Certificate before making a determination as to whether the Covered Person s death is a result of an accident. The process to determine the cause of the Covered Person s death begins, upon the Company s receipt of the official Death Certificate. Claim Procedures: Proof of Loss: For a claim, for a loss for which this Policy provides any periodic payment contingent on continuing the loss, a written proof of loss must be provided to the insurer at the insurer s designated office before the ninety-first (91 st ) day after the termination of the period for which the insurer is liable. For a claim for any other loss, a written proof of loss must be provided to the insured at the insurer s designated office before the ninety-first (91 st ) day after the date of the loss. Failure to provide the proof within the required time does not invalidate or reduce any claim if it was not reasonably possible to get proof within the required time. In this event, the proof must be provided as soon as reasonably possible but not later than one (1) year after the time proof is otherwise required, except in the event of a legal incapacity. Payment of Claims: When Paid: The Company will pay claims immediately upon proof of loss with the death certificate, and an investigation having verified the Covered Person s death was accidental. The Company will notify the Beneficiary of either acceptance of the claim or the reason for denial no later than ten (10) business days from the receipt of the Death Certificate by the Company. The only exception to this ten (10) business day time frame is the need for an autopsy. An autopsy will extend the Company s time to accept or deny a claim. The Company has five (5) business days, after receipt of an autopsy report, to accept or deny a claim. In the event of payment, the Beneficiary agrees to assist in the arrangements and timing of the shipment of the Covered Person s body/remains. The remainder of the policy limits after deducting $6,000 Dollars for the Repatriation Service will be sent directly to Beneficiary, at the address listed on the Application, upon acceptance by the Company, of a claim. Payment of Repatriation: To Whom Paid: Benefits paid on account of a Covered Person s death after repatriation will be paid by the Company and the Beneficiary he or she has chosen. The First Beneficiary on the Application has sole authority to determine where the Covered Person s remains will be sent. This choice must be in writing and filed with the Company, or with the Program Administrator. If the Covered Person has not chosen a Beneficiary or if there is not a Beneficiary alive when the Covered Person dies, the Company will pay the repatriation benefit in the following order with the entire remainder of the policy limits after deducting $6,000 Dollars for the Repatriation Service benefit paid to: 1. wife or husband of Covered Person; but if not living to 2. child or children of Covered Person (split equally among the living children of the Covered Person); but if not applicable to 3. mother and/or father of Covered Person; but if not applicable to 4. sisters and/or brothers of Covered Person (split equally among the living sisters or brothers of the Covered Person). If no one in the above classes is living, the repatriation benefits will be paid according to the wishes of the Consulate of Mexico or Consulate of the respective country of Central America. The Company has no further obligation or duty to find a living relative of the Covered Person. 9

10 Beneficiary: Changes and Need to Notify Company Before Death of Covered Person: The Covered Person has the right to select or change the Beneficiary or decision maker in the event of the Covered Person s death. The original and/or existing Beneficiary s consent is not needed for the Covered Person to make a change of Beneficiary. Any such selection or change by the Covered Person must be in writing and presented to the agent of record, for this Policy. The Company will not be bound until the Company has received a signed copy of such change. No such change will be honored if such written change is first received by the Company after the death of the Covered Person, and this applies regardless of the date when the change was allegedly made. Payment Made: Any payment made by the Company, in good faith pursuant to this provision, shall fully discharge the Company to the extent of such payment. CANCELLATION BY COVERED PERSON This Policy may only be cancelled by the Covered Person. The Covered Person may cancel this Policy by mailing a request for cancellation to the Company at the address shown in this Policy. The effective date of cancellation stated in the notice will become the end of the Policy period. Return of earned premiums will be computed pro-rata based on the number of days left on the policy term. The Company s check or the check of the Company s representative mailed or delivered to the Covered Person will be sufficient tender of any refund of premium. LEGAL ACTIONS No action or law or in equity can be brought until after sixty (60) days following the date written proof of loss was given. No action can be brought after three (3) years from the date written proof is required. INADVERTENT ERROR The insurance of a Covered Person will not be prejudiced by the failure on the part of the Company to transmit reports, pay premium or comply with any of the provisions of this Policy, when such failure is due to an inadvertent error or clerical mistake. Commercial Alliance Insurance Company Secretary President YOU ARE COVERED FOR REPATRIATION FOR ACCIDENTAL DEATH ONLY. THE POLICY DOES NOT PAY BENEFITS FOR LOSS CAUSED BY SICKNESS. READ YOUR POLICY WITH CARE. 10