General Conditions of Driver and Passenger Personal Accident Insurance

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1 General Conditions of Driver and Passenger Personal Accident Insurance Table of Contents General Provisions. Definitions...1 Subject and Scope of Insurance...1 Exclusions of Allianz Liability for Permanent Health Damage, Treatment Expenses and Death Resulting from an Accident...1 Insurance Contract...2 I Post-accident Procedure and Payment of Benefits...2 II Assessment and Payment of Permanent Health Damage Benefits...3 III Assessment and Payment of Death Benefits....3 IV Assessment and Payment of Benefits in Respect of Treatment Expenses Incurred within the Republic of Poland....4 Commencement and Termination of Liability...4 Insurance Premium Procedure in Case of Accident Event, Policyholder s and Insured s Obligations Final Provisions....4

2 General Conditions of Driver and Passenger Personal Accident Insurance General Provisions. Definitions These General Conditions of Driver and Passenger Personal Accident Insurance, hereinafter referred to as the GCI, shall apply to insurance contracts made by Towarzystwo Ubezpieczeń i Reasekuracji Allianz Polska S.A., hereinafter referred to as Allianz, with natural persons, bodies corporate and unincorporated bodies, hereinafter referred to as Policyholders. Under these GGI Allianz shall enter into contracts of insurance covering drivers and passengers against accidents arising from the movement of motor vehicles bearing registration plates issued in the Republic of Poland to the current owner. The insurance contract shall cover the consequences of accidents causing the following to the persons mentioned in paragraph 1: 1) permanent health damage arising: a) in connection with the movement of a vehicle; b) when entering and exiting a vehicle; c) directly when loading or unloading the vehicle; d) when the vehicle is being stopped, parked or repaired. 2) treatment expenses incurred in consequence of an accident that has occurred in the circumstances mentioned in subparagraph 1; 3) death in consequence of an accident that has occurred in the circumstances mentioned in subparagraph 1; 4) death referred to in subparagraph 3, following permanent health damage and payment of a related benefit. Definitions 1) Attending physician the physician taking care of the Insured after the accident occurred. 2) Authorized physician a physician appointed by Allianz and authorized to request medical facilities to provide medical records of the Insured and to prepare medical expert opinions, including medical examination (certifying physician). 3) Acting under the influence of alcohol acting in a state where blood alcohol content in the body amounts or leads to: a) blood alcohol concentration above 0.2, or b) alcohol content in 1 dm3 of breath above 0.1 mg. 4) Accident a sudden and accidental event which simultaneously meets all of the following criteria: a) is independent of the will and health condition of the Insured, b) is due to an external cause of a fortuitous nature, which was the direct and sole cause of the event, c) occurred within the period between the date of commencement and the date of termination of liability of Allianz to the Insured, d) was the direct and sole cause of the event for which Allianz is liable, e) there is adequate causality between the consequences of the event and the external cause of the event; and in consequence of the event the Insured has suffered bodily injury, health disorder or died. 5) Motor vehicle an automotive vehicle, agricultural tractor, moped or trailer registered under the road traffic law; a low-speed vehicle within the meaning of the road traffic law. 6) Movement of a motor vehicle a situation where a vehicle moves, driven by an engine/motor or by the force of inertia. 7) Permanent health damage permanent bodily injury or loss of health resulting from an accident, impairing bodily functions beyond improvement. 8) Policyholder a natural person, body corporate or unincorporated body entering into a contract of insurance against personal accidents arising from the movement of a motor vehicle. 9) Insured the driver and passengers of the vehicle specified in the insurance contract insofar as their number does not exceed that specified in the registration document. 10) Beneficiary a person or persons named by the Insured in writing as being entitled to receive a benefit in the event of the Insured s death. The Insured can name the Beneficiary both on entering into the insurance contract and at any time during the continuance thereof. The Insured shall have the right to change the Beneficiary at any time during the continuance of the insurance contract. Such change shall be effective as of the date of receipt of the request by Allianz. In a situation where the sum of percentage shares of the Beneficiaries does not equal 100, the persons shares in the benefit amount due shall be determined on a pro rata basis according to the proportions arising from the Insured s designation. If no Beneficiary is named in writing, the provisions of 5 Part III, paragraph 5 of GCI shall apply; 11) Entering a vehicle the activities the driver or passengers must perform from the moment the door is opened from outside the vehicle until they are inside the vehicle. 12) Exiting a vehicle the activities the driver or passengers of the vehicle must perform from the moment the door is opened from inside the vehicle until they are outside the vehicle. Subject and Scope of Insurance Depending on the option selected by the Policyholder, Allianz shall provide insurance cover to the driver or to the driver and passengers of the vehicle specified in the contract. Insurance cover shall include permanent consequences of accidents defined in subparagraphs 1, 3 and 4 of paragraph 2 that have occurred both within and outside the territory of the Republic of Poland, and with regard to paragraph 2 (2) (treatment expenses) insurance cover shall include the refund of treatment expenses incurred only within the territory of the Republic of Poland in accordance with 4 (7) of the GCI. The number of persons carried in the vehicle must not exceed the number of persons specified in the registration document of the vehicle. Exclusions of Allianz Liability for Permanent Health Damage, Treatment Expenses and Death Resulting from an Accident The liability of Allianz shall be excluded in the following cases: 1) accidents caused intentionally by the Insured, self-inflicted injury or injury inflicted at the Insured s request, suicidal attempt or consequences of suicide, whether sane or insane; 2) active and illegal participation by the Insured in acts of violence, civil commotions or riots; 3) accidents resulting from any pathological conditions, including consequences of diseases classified by the International Statistical Classification of Diseases and Related Health Problems ICD 10 as mental and behavioural disorders (F00-F99), 4) accidents resulting the Insured acting under the influence of alcohol or when affected by intoxicants, psychotropic agents or drug substitutes within the meaning of the Drug Addiction Control Act, medicines not prescribed by a physician or prescribed by a physician but used contrary to medical advice or contrary to the indications for the use thereof; 5) consequences of accidents sustained when the Insured was driving a vehicle without being licensed to do so or driving a vehicle that has not been declared roadworthy; 6) submission to conservative or operative treatment, unless the medical advice to perform such treatment is directly related to an accident; 7) any accidents occurring as a result of a war, hostilities, armed conflicts, civil commotions, riots, coup d état or acts of terror; 8) consequences of events resulting from the commitment or attempted commitment by the Insured of an act meeting the statutory definition of an intentional offence; 9) consequences of accidents caused directly or indirectly by nuclear energy, radioactive radiation and magnetic fields, if harmful to human beings; 10) the Insured participating in competitions as a driver, driver s assistant or passenger of any motor vehicles, including all types of test driving; 11) consequences of accidents sustained when performing stunts; 12) the poisoning of the Insured with solid or liquid substances that have entered the body through the respiratory tract, the alimentary system or through the skin, unless such poisoning has been caused by an accident; 13) accidents resulting from gross negligence unless the provisions of Article of the CC apply; 14) accidents where the passenger has chosen to ride with a driver of a motor vehicle being aware that the driver is under the influence of alcohol, intoxicants, psychotropic substances or drug substitutes within the meaning of drug addiction prevention regulations; 15) where the number of passengers carried in the vehicle at the time of the accident exceeds the number of persons specified in the registration document; NNKPE-O03 12/13 1

3 16) post-traumatic psychosis, encephalopathy or neurosis resulting from an accident. In addition to the provisions of 3 (1), the scope of cover for treatment expenses within the territory of the Republic of Poland does not exceed: 1) procedures for aesthetic reasons; 2) treatment by a physician being a member of the Insured s family; 3) procedures or treatment not recognized scientifically and medically; 4) treatment expenses resulting from failure to follow the advice of the attending physician; 5) the cost of foodstuffs and stimulants; 6) the cost of patient nursing and the cost of travel to and stay in sanatoriums and spas for therapeutic purposes. The insurance shall cover only the benefits set forth in the contract and in no event shall it cover any claims for compensation for any physical or moral harm, pain or suffering, or economic losses arising from the loss or damage to things owned by the Insured. Insurance Contract Unless agreed otherwise, the insurance contract shall be made on the basis of a written proposal form for a period of one year (annual insurance). The conclusion of the insurance contract shall be confirmed by an insurance document a policy. The sums insured for permanent health damage and for accidental death referred to in 2 (2) (3) of the GCI per insured person are fixed as follows depending on the selected option: 1) NNW a) The sum insured for permanent health damage shall be PLN health damage shall be PLN c) The sum insured for accidental death shall be PLN per insured 2) NNW a) The sum insured for permanent health damage shall be PLN health damage shall be PLN c) The sum insured for accidental death shall be PLN per insured 3) NNW a) The sum insured for permanent health damage shall be PLN health damage shall be PLN c) The sum insured for accidental death shall be PLN per insured 4) NNW a) The sum insured for permanent health damage shall be PLN health damage shall be PLN c) The sum insured for accidental death shall be PLN per insured The sum insured for accidental death to in 2 (2) (4) of the GCI, under each of the options described in paragraph 3 and for each insured person shall be the amount resulting from the difference between: the sum insured for death and the amount of benefit paid for permanent health damage. The insurance shall cover benefits for permanent health damage resulting from an accident, with the proviso that the benefit to be paid shall correspond to the percentage of the sum insured representing permanent health damage suffered by the Insured, up to the maximum amount of the sum set forth in the insurance contract, subject to paragraph If permanent health damage resulting from an accident is assessed to be at least a 90%, the Insured shall be eligible for a benefit calculated on the amount set forth as the sum insured in respect of the double benefit for permanent health damage in accordance with the health damage percentage awarded. Allianz shall refund treatment expenses incurred within the territory of the Republic of Poland (evidenced by original personal bills issued and recognized necessary by an authorized physician), in connection with an insured accident, irrespective of the place of accident (whole world), up to the amount of 10% of the sum insured set forth in the insurance contract in respect of permanent health damage. 8. Only expenses incurred within 365 days from the date of accident shall be refundable. 9. The following shall be recognized as treatment expenses within the territory of the Republic of Poland: medical fees; outpatient/ inpatient treatment expenses; cost of outpatient rehabilitation procedures in healthcare establishments; cost of drugs and other medications; plastic surgery expenses; cost of medical transport by medical rescue services necessitated by the Insured s health condition; costs of purchase of prosthetic appliances and aids; 8. cost of purchase of rehabilitation equipment; 9. cost of purchase of dressing materials; 10. cost of purchase of a wheelchair; 1 costs of X-ray, USG and other diagnostic examinations necessary in the course of post-accident treatment. 10. Allianz may refrain from refunding treatment expenses found unjustified by the authorized physician. 1 Treatment expenses shall be covered irrespective of the degree of permanent health damage awarded. 1 Benefits in respect of treatment expenses shall be paid only if Allianz admits the accident claim. 1 If the Insured who has sustained an accident is covered under several insurance contracts, the benefit in respect of treatment expenses must not exceed the actual and evidenced expenses concerned. Allianz shall not pay a benefit in respect of any treatment expenses that have been refunded under other insurance contracts. I Post-accident Procedure and Payment of Benefits Benefits under the insurance contract shall be paid in Polish zlotys. Allianz shall pay the benefit within: 1) 30 days from receipt of the written claim notification; 2) where the circumstances necessary to determine the insurer s liability or the amount of the indemnity are impossible to determine within the above time limit, the indemnity shall be payable within 14 days from the date on which the clarification of such circumstances becomes possible with the exercise of due care and diligence, whereas an indisputable part shall be paid within the time limit laid down in subparagraph If no benefit is payable, Allianz shall inform the Insured thereof in writing or, in the case of the Insured s death, loss payees, within the time limit set forth in paragraph 2, stating the legal bases justifying the refusal of benefit payment. In determining the degree of permanent health damage, the type of work or activities performed by the Insured shall not be taken into consideration. On entering into the insurance contract, the Insured shall release the attending physicians from the obligation of medical secrecy in relation to Allianz and agrees to make medical records available to authorized physicians. 2

4 II Assessment and Payment of Permanent Health Damage Benefits The amount of the benefit under personal accident insurance shall be determined after the existence of causality has been ascertained between the accident and permanent health damage. The benefit shall be available to the Insured according to the degree (percentage) of permanent health damage and it shall be paid in the amount corresponding to the percentage of the sum insured representing permanent health damage suffered by the Insured, up to the maximum amount of the sum insured set forth in the insurance contract, subject to 4 (5). The indisputable part of the benefit shall be determined on the basis of medical records of completed treatment and rehabilitation. Having complete medical records available for injuries other than multiple organ injuries, the authorized physician may assess the permanent health damage within the time limits applicable to the indisputable part. For accident events outside the territory of the Republic of Poland, medical records shall be allowed to be submitted in English and in the official language of the state in which the accident has occurred. The degree of permanent health damage should be determined finally by an Allianz certifying physician or physicians immediately after completion of treatment and rehabilitation, not later than the end of the 24th month after the accident date. The existence of permanent health damage shall be certified by the authorized physician or Allianz certifying physicians based on documents and examination results supplied, with the provision that: 1) the percentage of permanent health damage is certified on the basis of the Accident Permanent Health Damage Percentage Assessment Table in force at Allianz at the date of the insurance contract. The table shall be furnished prior to the conclusion of the insurance contract and it shall be available at the Allianz office any time after the conclusion of the contract, and it shall be immediately furnished to the Policyholder (Insured) at their request; 2) the certification by the Allianz certifying physician of the Insured s permanent health damage in consequence of an accident may be subject to verification by the Allianz regional medical consultant for compliance with certification procedures. 8. If several physical functions have been impaired as a result of an accident, the degrees of permanent health damage shall be aggregated. However, no permanent health damage in excess of 100% shall be recognized. 9. If an organ or system has been lost or damaged as a result of an accident, the functions of which were previously impaired (due to a disease or preexiting disability), the percentage of permanent health damage shall be determined as the difference between the post-accident condition and the condition existing immediately before the accident. 10. Allianz reserves the right to arrange for medical expert opinions with a view to determining the degree of permanent health damage. 1 Allianz shall reimburse the Insured for any public transport expenses within the territory of the Republic of Poland, incurred to travel to the offices of the Allianz certifying physicians as indicated by Allianz, based on a document showing the means of transport and the amount of expenses incurred (e.g. municipal transport ticket, Polish National Railways ticket). The cost of travel by means other than public transport shall be refundable only subject to prior approval and confirmation in writing by Allianz of the legitimacy of such choice. The above approval may only be given before the appointed date of the certification examination. 1 Should the Insured waive further post-accident medical treatment explicitly prescribed by physicians, the degree of permanent health damage shall be determined on the basis of the condition that, to the best knowledge of the Allianz certifying physician, could be determined after the completion of the prescribed treatment. 1 After the occurrence of an accident, the Insured shall be required to immediately submit to medical care and take measures to mitigate the consequences of the accident by following medical advice. 1 If the Insured fails to appear three times, without giving a good reason for such failure, for a consultation arranged in order to have the degree of permanent health damage determined by a physician appointed by Allianz, despite having been notified three times by letter sent to the last address given by the Insured, Allianz reserves the right to refuse to pay the benefit, unless Allianz has sufficient knowledge of the degree of the Insured s permanent health damage. 1 The benefit for permanent health damage shall be payable by Allianz on the basis of evidence of the event giving rise to liability of Allianz. The claim notification for permanent health damage should be accompanied by documents indicated by Allianz as being necessary for the claim to be examined. The above documentation may include: 1) completed claim notification form; 2) description of the circumstances of the accident; 3) document confirming the Insured s identity; 4) certification of completed treatment and rehabilitation, if any; 5) police report in case the police have been notified, if any; 6) a decision terminating criminal or misdemeanour proceedings if such proceedings were conducted in the case concerned, as well as other documents in hand on pending proceedings, which may confirm the legitimacy or value of claim; 7) medical records of the treatment and rehabilitation process if treatment or rehabilitation have taken place; 8) driving licence if the Insured has suffered an accident as the vehicle driver. 1 The basis for the payment of benefits by Allianz shall be the submission of the original required documents or their copies certified to be true copies, unless other provisions require original documents. Document copies may be certified to be true copies by any of the following persons: 1) an employee of the institution issuing the document concerned; 2) a notary; 3) authorized persons named by Allianz. 18. If the Insured has died due to causes unrelated to an accident, and the degree of permanent health damage has not been determined before, the degree of permanent health damage shall be determined by authorized physicians appointed by Allianz, according to medical knowledge and based on the medical records collected. III Assessment and Payment of Death Benefits The benefit shall be payable if the Insured s death is found to have been caused directly by an accident suffered by the Insured. The benefit in respect of accidental death shall be payable if the Insured s death has occurred within one year from the accident date. If the Insured has died in consequence of an accident within one year of the date of the accident, Allianz shall pay the Beneficiary a single benefit in accordance with 4 (3) equal to the full sum insured for death as defined in the insurance contract, provided that no benefit has been paid previously for permanent health damage. However, if the permanent health damage benefit has already been paid, the death benefit shall be reduced by the amount paid previously, in accordance with 4 (4). The benefit in respect of the Insured s death shall be payable by Allianz on the basis of the Beneficiary s evidence to the effect that death has occurred as a result of an accident. The claim notification for accidental death should be accompanied by documents indicated by Allianz as being necessary for the claim to be examined. The above documentation may include: 1) completed claim notification form; 2) death certificate; 3) documents describing/confirming the connection between death and an accident; 4) description of the circumstances of the accident; 5) police report in case the police have been notified, if any; 3

5 7) document confirming the Insured s identity; 8) medical records of the treatment process if treatment or rehabilitation have taken place; 9) a decision terminating criminal or misdemeanour proceedings if such proceedings were conducted in the case concerned, as well as other documents in hand on pending proceedings, which may confirm the legitimacy or value of claim; 10) driving licence if the Insured was driving a vehicle. The benefit for the Insured s death shall be available to the named person (Beneficiary) or, failing such person, in the following order of priority: 1) the spouse; 2) children in equal parts (in the absence of spouse); 3) children in equal parts (in the absence of spouse); 4) siblings in equal parts (in the absence of parents, children and spouse); 5) other legal heirs (in the absence of the persons mentioned above). IV Assessment and Payment of Benefits in Respect of Treatment Expenses Incurred within the Republic of Poland After the occurrence of an accident, the Insured shall be required to submit to Allianz original bills and proofs of payment thereof, for the purposes of refunding treatment expenses within the Republic of Poland. Commencement and Termination of Liability Unless agreed otherwise, insurance cover shall commence at the date stated in the insurance contract, but no earlier than the day following premium payment. The cover provided by Allianz shall expire on termination of the insurance contract. The insurance contract shall terminate: 1) upon the lapse of the period for which the insurance was made; 2) as of the date of withdrawal from the insurance contract; 3) upon deregistration of the vehicle; 4) as of the date of sale of the vehicle. 5) as of the due date on which premium fails to be paid as provided in the insurance contract, resulting in termination of the liability of Allianz after a demand for payment has been served on the Policyholder if payment is not made within seven days of receipt of the demand by the Policyholder. In the absence of such demand from the Insurer, insurance cover shall not cease and Allianz shall be entitled to a premium for the entire period of cover. The Policyholder may withdraw from the insurance contract within 30 days from the conclusion of the contract for natural persons and, in the case of business operators, within 7 days from the conclusion of the contract. Withdrawal from the contract shall not relieve the Policyholder from the obligation to pay premiums for the period of insurance cover provided by Allianz. Insurance Premium The insurance premium shall be calculated in accordance with the scale of premiums in force at the date of the contract. Unless agreed otherwise, the premium shall be payable in advance for the entire insurance period. The refundable premium amount shall be determined in proportion to the unused insurance period. 8. Procedure in Case of Accident Event, Policyholder s and Insured s Obligations After the occurrence of an accident the Insured shall be required to provide assistance to the accident victims and: 1) notify the police and the ambulance service of the road accident and its victims; 2) after symptoms of accident injury have manifested themselves, submit to medical care as soon as possible and take measures in order to mitigate the consequences of the accident by following medical advice; 3) notify Allianz of the occurrence of the accident by telephone or in writing, no later than three years after the event the address and telephone number are stated in the insurance document. 4) submit to Allianz documents necessary to determine the legitimacy of the claim and the benefit amount, and provide all information required by Allianz in this regard, complete the claim notification form provided by Allianz and return it to Allianz; 5) make sure that the documents and information required by Allianz are furnished without undue delay; 6) enable Allianz to obtain information on the Insured s health, in particular from physicians taking care of the Insured after the accident. 9. Final Provisions Any claims as may be made by Allianz or by the Insured/Policyholder under this contract shall be time-barred after a period of three years. Any amendments to the contract, notices and explanations shall be null and void unless made in writing. The Policyholder and Allianz are required to inform each other of any change of address. If a party fails to notify the other about a change of address, letters sent to the party s last known address become effective at the time they would be delivered to the addressee if it were not for the change of address. Any matters not provided for in these GCI shall be governed by the provisions of the Civil Code, the Act on insurance activity and other applicable provisions of the Polish law. Any complaints connected with the conclusion or performance of the insurance contract may be submitted by the Policyholder, the Insured or the Beneficiary to the Head Office of TU Allianz Polska S.A. (Headquarters). Complaints may also be submitted to the Insurance Ombudsman. Action for claims arising from insurance contracts may be brought either under the rules of general jurisdiction (before a court having territorial jurisdiction over the registered office of Allianz in Warsaw), or by a court having jurisdiction over the place of residence of registered office of the Policyholder, the Insured, the Beneficiary or the loss payee under the insurance contract. These GCI were adopted by Resolution of the of TUiR Allianz Polska S.A. No 83/2011 of 7 July 2011 and shall apply to insurance contracts made on or after 1 August 201 In the event of early termination of the contract Allianz shall be entitled to premium for the period in which it provided insurance cover. The Policyholder shall be entitled to premium refund in the event of withdrawal from the insurance contract prior to the commencement of insurance cover. Premium shall be refundable in full, with no administration fees charged. The Policyholder shall be eligible for refund of premium for the period of unused insurance cover. Paweł Dangel President of the Zbigniew Świątek Piotr Dzikiewicz Dariusz Karłowicz 4

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