personal ccident insurance
PERSONL CCIDENT INSURNCE POLICY INSURING GREEMENT....1 DEFINITIONS... 1 COVERGES Option 1 On The Move Description of... 3 Schedule of enefits Level 1... 5 Level 2... 6 Option 2 ll The Time Description of... 7 Schedule of enefits Level 1... 8 Level 2... 9 EXCLUSIONS...1 0 EXCEPTIONS ge of pplicant... 11 enefit Reduction... 11 Limit per Claimant...1 1 Limit for Multiple Claimants... 11 PROVISIONS eneficiary(ies).... 11 Payment in the Event of Loss of Life of the Insured... 11 Payment in the Event of Loss of Life of the Spouse or Dependent...1 2 Term of...1 2 Currency... 12 STTUTORY CONDITIONS...1 3 pril 1, 2012
INSURING GREEMENT PERSONL CCIDENT INSURNCE (The Policy ) In consideration of the premium charged, lberta Motor ssociation Insurance Company agrees that the Insured named on the Personal ccident Certificate of Insurance, issued by lberta Motor ssociation Insurance Company, is insured under this Policy and that we will pay to the Insured, subject to the definitions, exclusions, exceptions, provisions and statutory conditions of this Policy, the amount(s) specified in the Schedule of enefits under the purchased coverage option for loss of life or Injuries resulting directly and independently of all other causes, from accidental death or accidental Injuries which arise out of events or activities described in the Description of. This Policy provides accident benefits that are payable in one sum. The Injuries which are covered and the benefit payable for the covered Injury are outlined in the Schedule of enefits in this Policy. For greater certainty, this Policy does not provide hospitalization or disability insurance. DEFINITIONS In this Policy, the following words have their meanings set out below. This section defines several key terms used in this policy. You or Your means the person(s) named as Insured on the Insurance Certificate and, while living in the same household, his or her Spouse or adult interdependent partner and eligible dependents. Insured means the person named on the Insurance Certificate. Spouse means the person to whom the Insured is married or the adult independent partner of the Insured. dult interdependent partner means either of two persons who has: (a) lived with the other person in a relationship of interdependence (i) for a continuous period of not less than three years, or 1
(ii) of some permanence, if there is a child of the relationship by birth or adoption, or (b) entered into an adult interdependent partner agreement with the other person in accordance with the dult Interdependent Relationships ct. Dependent means: (a) your unmarried children including legally adopted children and stepchildren, who are over the age of 13 days and under the age of 19 years of age and who are dependent on you for the main part of their support and maintenance; (b) unmarried children who have passed their 19th birthday and are a full-time student at an accredited college or university. Such children will continue to be an eligible dependent up to their 25th birthday or the date they cease to be a full-time student, whichever occurs first; (c) children who have passed their 19th birthday and because of mental or physical infirmity are dependent on you for financial support. We or Us means the lberta Motor ssociation Insurance Company. ccident means the sudden and unexpected event or activity that resulted in the Injury. enefit means the amounts specified in the Schedule of enefits table in Canadian dollars. eneficiary means a person designated to receive the money payable from an insurance policy in the event of death of the Insured. Injury(ies) means loss of life, loss of use of a limb(s), or complete and total loss of sight, speech and/or hearing in the combinations set out in the Schedule of enefits. 2
COVERGES is provided for loss of life, sight, speech and/or hearing and loss of use of limbs as specified in the Schedule of enefits. Loss of sight, speech and/or hearing means complete, total and irrecoverable loss. Loss of use of a limb means total and irrecoverable loss of use. This section outlines the coverage provided for each coverage option. enefits are paid in accordance with the selected coverage option and coverage level. OPTION 1 ON THE MOVE COVERGE If the Insurance Certificate indicates On The Move coverage, we provide insurance as described below: DESCRIPTION OF COVERGE 1. Personal Transportation or as a Pedestrian You are insured while: a) Driving, riding as a passenger in, boarding or alighting from any private passenger automobile, snowmobile, farm vehicle, recreational vehicle, bicycle while used for personal transportation, or other self-propelled land vehicle, watercraft or aircraft, but not as an operator or member of the crew of an aircraft used for pleasure purposes, provided that: and i) any such self-propelled land vehicle, bicycle or watercraft is operated in strict compliance with any applicable licensing and registration laws and not being used in any off-road extreme sport; and ii) the operator of any such self-propelled land vehicle, bicycle or watercraft is by law, authorized and qualified to drive, and not engaged in a race, speed test or illicit prohibited trade; 3
b) eing struck while a pedestrian by any self-propelled land vehicle. Private passenger vehicle means an automobile not licensed to carry passengers for hire which is being used for pleasure purposes only. 2. On a Scheduled irline Flight or Common Carrier You are insured while travelling as a passenger on, or boarding or alighting from a: a) Scheduled irline Flight: any aircraft licensed to carry passengers and flown by a duly licensed pilot, but excluding any flight for any other purpose than the primary purpose of transportation of fare-paying passengers; and b) Common Carrier: any licensed transportation used as a common carrier for passenger service such as a train, bus, taxi, ferry or ship; ut not while an operator or member of the crew riding in, boarding or alighting from any such Scheduled irline Flight or Common Carrier. 4
SCHEDULE OF ENEFITS If accidental death or accidental Injuries are suffered by you, your Spouse or Dependent, as a result of an event or activity described in the Description of, we will pay the appropriate enefit as indicated in the tables below. There are two coverage levels available. The enefits payable for a Dependent are doubled when there is no Spouse in the household. Level 1 Loss of Life or Injuries Insured Spouse Dependent Loss of Life $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 Loss of use of both hands, both $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 feet or both eyes Loss of use of one hand and $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 one foot Loss of use of one hand and one eye or one $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 foot and one eye Loss of speech and hearing $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 Loss of use of one arm or one $37,500 $75,000 $18,750 $37,500 $3,750 $7,500 leg Loss of use of one hand or one $33,300 $66,600 $16,650 $33,300 $3,330 $6,660 foot or one eye Loss of speech or hearing $25,000 $50,000 $12,500 $25,000 $2,500 $5,000 5
Level 2 Loss of Life or Injuries Insured Spouse Dependent Loss of Life $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 Loss of use of $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 both hands, both feet or both eyes Loss of use of $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 one hand and one foot Loss of use of $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 one hand and one eye or one foot and one eye Loss of speech $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 and hearing Loss of use of $75,000 $150,000 $37,500 $75,000 $7,500 $15,000 one arm or one leg Loss of use of $66,600 $133,200 $33,300 $66,600 $6,660 $13,320 one hand or one foot or one eye Loss of speech or hearing $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 6
OPTION 2 - LL THE TIME COVERGE If the Insurance Certificate indicates ll The Time coverage, we provide insurance as described below: Description Of 1. ny ccident Not Excluded You are insured for Injuries resulting from any event or activity not specifically excluded under the Exclusions of this Policy. 2. On a Scheduled irline Flight or Common Carrier You are insured while travelling as a passenger on, or boarding or alighting from a: a) Scheduled irline Flight: any aircraft licensed to carry passengers and flown by a duly licensed pilot, but excluding any flight for any other purpose than the primary purpose of transportation of fare-paying passengers; and b) Common Carrier: any licensed transportation used as a common carrier for passenger service such as a train, bus, taxi, ferry or ship; ut not while an operator or member of the crew riding in, boarding or alighting from any such Scheduled irline Flight or Common Carrier. 7
SCHEDULE OF ENEFITS If accidental death or accidental Injuries are suffered by you, your Spouse or Dependent, as a result of an event or activity described in the Description of, we will pay the appropriate enefit as indicated in the tables below. The enefits payable for a Dependent are doubled when there is no Spouse in the household. Level 1 Loss of Life or Insured Spouse Dependent Injuries Loss of Life $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 Loss of use of $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 both hands, both feet or both eyes Loss of use of $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 one hand and one foot Loss of use of $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 one hand and one eye or one foot and one eye Loss of speech $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 and hearing Loss of use of $37,500 $75,000 $18,750 $37,500 $3,750 $7,500 one arm or one leg Loss of use of $33,300 $66,600 $16,650 $33,300 $3,330 $6,660 one hand or one foot or one eye Loss of speech or hearing $25,000 $50,000 $12,500 $25,000 $2,500 $5,000 8
Level 2 Loss of Life or Injuries Insured Spouse Dependent Loss of Life $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 Loss of use of $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 both hands, both feet or both eyes Loss of use of $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 one hand and one foot Loss of use of $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 one hand and one eye or one foot and one eye Loss of speech $100,000 $200,000 $50,000 $100,000 $10,000 $20,000 and hearing Loss of use of $75,000 $150,000 $37,500 $75,000 $7,500 $15,000 one arm or one leg Loss of use of $66,600 $133,200 $33,300 $66,600 $6,660 $13,320 one hand or one foot or one eye Loss of speech or hearing $50,000 $100,000 $25,000 $50,000 $5,000 $10,000 9
THE FOLLOWING SECTIONS RE PPLICLE TO OTH ON THE MOVE ND LL THE TIME COVERGE OPTIONS. EXCLUSIONS You are not insured for any Loss of Life or Injuries partly, directly or indirectly caused by: 1. suicide or attempted suicide while sane or insane; 2. intentional self-inflicted injury; The following exclusions and exceptions outline the situations in which this coverage is limited or restricted. 3. physical or mental infirmity; 4. insurrection or war, whether declared or not, or any related act, or participation in any riot or civil disorder; 5. terrorist activity of any kind or any related act or consequence, including the explosion of weapons of mass destruction, and/or the release of weapons of mass destruction, whether they involve an explosive sequence or not; Or while: 6. attempting or committing a criminal offence; 7. participating in any manoeuvres or training exercises of the rmed Forces; 8. the operator of a self-propelled land vehicle, watercraft or bicycle or while a pedestrian when under the influence of: 10 a) any drugs, unless administered in accordance with the advice of a licensed physician; b) alcohol, when the alcohol concentration in the blood exceeds 80 milligrams of alcohol in 100 millilitres of blood; or c) any other illicit substance. 9. operating any self-propelled land vehicle, bicycle, or watercraft unless by law authorized and qualified to drive;
10. participating in any race or speed test. EXCEPTIONS ge of pplicant is not available to new applicants 75 years of age or older. enefit Reduction enefits payable to you will be reduced by 50% upon the Insured reaching the age of 80 years. Limit per Claimant If the Insured, Spouse or Dependent sustains more than one of the Injuries described in the Schedule of enefits as the result of any one ccident, we will pay the enefit indicated for each Injury but in no event will the total amount payable to each claimant exceed the total enefit payable for loss of life. Limit for Multiple Claimants The maximum amount payable by us under all Personal ccident Insurance policies arising from any one ccident, regardless of the number of claims, is $30,000,000. PROVISIONS eneficiary(ies) The Insured may designate or change a eneficiary(ies) upon written notice to us, subject to the laws of the Province of lberta. It is important to keep your beneficiary up to date. Payment in the Event of Loss of Life of the Insured In the event of the death of the Insured, the enefit payable will be paid to the person(s) designated as eneficiary by the Insured and shown on our records. If no eneficiary has been designated, or if there is no surviving eneficiary(ies) the enefit will be paid to the estate of the Insured. 11
Payment in the Event of Loss of Life of the Spouse or Dependent In the event of the death of the Spouse or a Dependent, the enefit payable will be paid to the Insured. If the Insured is deceased, the enefit will be paid to the person(s) designated as eneficiary by the Insured and shown on our records. If no eneficiary has been designated or if there are no surviving eneficiary(ies), the enefit will be paid to the estate of the Insured. Term of The term of this Policy commences on the effective date stated on the Insurance Certificate and is continuous until the expiry date stated on the Insurance Certificate or until such time this Policy is terminated in accordance with the Statutory Conditions set out below. We reserve the right to modify this Policy. Currency ll enefits are paid in Canadian funds. 12
STTUTORY CONDITIONS The Contract The application, this policy, any document attached to this policy when issued, and any amendment to the contract agreed on in writing after the policy is issued, and any amendment to the contract agreed on in writing after the policy is issued, constitute the entire contract, and no agent has authority to change the contract or waive any of its provisions. Waiver The insurer shall be deemed not to have waived any condition of this contract, either in whole or in part, unless the waiver is clearly expressed in writing signed by the insurer. Copy of pplication The insurer shall, on request, furnish to the insured or to a claimant under the contract a copy of the application. Material Facts No statement made by the insured or person insured at the time of application for the contract shall be used in defence of a claim under or to avoid this contract unless it is contained in the application or any other written statements or answers as evidence of insurability. Termination by Insured The insured may terminate this contract at any time by giving written notice of termination to the insurer by registered mail to its head office or chief agency in the province, or by delivery thereof to an authorized agency of the insurer in the province, and the insurer shall on surrender of this policy refund the amount of premium paid in excess of the short-rate premium calculated to the date of receipt of such notice according to the table in use by the insurer at the time of termination. Termination by Insurer 1. The insurer may terminate this contract at any time by giving written notice of termination to the insured and by refunding concurrently with the giving of notice the amount of premium paid in excess of the pro rata premium for the expired time. 13
2. The notice of termination may be delivered to the insured, or it may be sent by registered mail to the latest address of the insured on the records of the insurer. 3. Where the notice of termination is delivered to the insured, 5 days notice of termination shall be given; where it is mailed to the insured, 10 days notice of termination shall be given, and the 10 days shall begin on the day following the date of mailing of notice. Notice of Proof and Claim The insured or a person insured, or a beneficiary entitled to make a claim, or the agency of any of them, shall (a) give written notice of claim to the insurer 14 (i) by delivery thereof, or by sending it by registered mail to the head office or chief agency of the insurer in the province, or (ii) by delivery thereof to an authorized agency of the insurer in the province, not later than 30 days from the date a claim arises under the contract on account of accidental death or accidental injury, (b) within 90 days from the date a claim arises under the contract on account of accidental death or accidental injury, furnish to the insurer such proof as is reasonably possible in the circumstances of the happening of the accident or commencement of the sickness or disability, and the loss occasioned thereby, the right of the claimant to receive payment, his age and the age of the beneficiary if relevant, and (c) if so required by the insurer, furnish a satisfactory certificate as to the cause or nature of the accidental death or accidental injury for which claim may be made under the contract and as to the duration of such disability. Failure to Give Notice or Proof Failure to give notice of a claim or furnish a proof of claim within the time prescribed by this Statutory Condition does not invalidate the claim if the notice or proof is given or furnished as soon as reasonably possible, and in no event later than one year from the date of the
accident or the date a claim arises under the contract on account of an accidental death or accidental injury if it shown that it was not reasonably possible to give notice or furnish proof within the time so prescribed. Insurer to Furnish Forms for Proof of Claim The insurer shall furnish forms for proof of claim within 15 days after receiving notice of claim, but where the claimant has not received the forms within that time he may submit his proof of claim in the form of a written statement of the cause or nature of the accidental death or accidental injury giving rise to the claim and of the extent of the loss. Rights of Examination s a condition precedent to recovery of insurance money under this contract, (a) the claimant shall afford to the insurer an opportunity to examine the person of the person insured when and so often as it reasonably requires while the claim hereunder is pending, and (b) in the case of death of the person insured, the insurer may require an autopsy subject to any law of the applicable jurisdiction relating to autopsies. When Money is Payable ll money payable under this contract shall be paid by the insurer within 60 days after it has received proof of claim. Limitation of ctions n action or proceeding against the insurer for the recovery of a claim under this contract shall not be commenced more than two years after the date the insurance money became payable or would become payable if it had been a valid claim. Underwritten by the lberta Motor ssociation Insurance Company 15
Designation or Change of eneficiary Form This form is used to designate or change the beneficiary listed on your Personal ccident Insurance policy. We recommend you review your beneficiary information when life-changing events occur and make changes as necessary to your designated beneficiary. Member Information Member Name: Membership #: Insured Name: Policy#: Option: eneficiary Information I revoke all prior named beneficiary designations under my policy. Change my beneficiary to: New eneficiary: eneficiary s Surname eneficiary s First Name Relationship Date of irth Percentage* (over)
eneficiary s Surname eneficiary s First Name Relationship Date of irth Percentage* *Percentage must equal 100% for all beneficiaries combined. I acknowledge that I have read and understand the information provided with this change in beneficiary. I understand that if I survive the designated beneficiary or beneficiaries the benefits under this policy for loss of life will be paid to my estate. Policyholder Signature: Witness Signature: Print Name: Print Name: Date: Date: (dd/mm/yyyy) (dd/mm/yyyy)
Thank you for your business. We at M Insurance value you as a member and policyholder. We re a full service insurance provider. We have you covered with a wide range of insurance products including auto, home, farm, RV, business, health, life, travel medical, events liability and extended auto warranty coverage. Plus, we re right here when you need us. For service call 1-800-615-5897 Monday - Friday 8:30 am to 8:00 pm Saturday 9:00 am to 5:00 pm 24-Hour Claims Service 1-888-426-2444 MInsurance.ca Printed on Recycled Paper W00140 30M 01/12 17661