Lloyd s Personal Accident Policy Whereas the Assured, with a view to effecting an insurance as hereinafter provided with the Underwriters (as defined below) has presented a proposal upon which the Underwriters have determined their terms and conditions We, Underwriting Members of the syndicates whose definitive numbers and proportions are shown in the Table attached hereto (hereinafter referred to as "the Underwriters"), hereby agree, in consideration of the payment to us by or on behalf of the Assured of the premium specified in the Schedule to insure against Bodily Injury in the manner and to the extent hereinafter provided. The Underwriters hereby bind themselves severally and not jointly, each for his own part and not one for another and therefore each of the Underwriters (and their Executors and Administrators) shall be liable only for his own share of his syndicate's proportion of any amounts payable hereunder. The identity of each underwriting member of the syndicates shown in the Table and the amounts of their respective shares may be ascertained by the Assured or the Assured's representative on application to Lloyd's Policy Signing Office quoting the Lloyd's Policy Signing Office number and date shown in the Table. In Witness whereof the General Manager of Lloyd s Policy Signing Office has signed this Policy on behalf of each of Us. LLOYD S POLICY SIGNING OFFICE General Manager K(USA) LMA3010 (08/11/2005)
THE ASSURED IS REQUESTED TO READ THIS POLICY AND, IF IT IS INCORRECT, RETURN IT IMMEDIATELY TO YOUR BROKER FOR ALTERATION. IN ALL COMMUNICATIONS THE POLICY NUMBER APPEARING IN LINE ONE OF THE SCHEDULE SHOULD BE QUOTED.
Words in bold print in this Policy have special meaning, as defined in the DEFINITIONS of this Policy IMPORTANT NOTICE PLEASE NOTE THAT THIS POLICY DOES NOT PROVIDE SICKNESS INSURANCE. THIS INSURANCE ONLY RELATES TO THE BENEFITS OF THE POLICY WHICH ARE SHOWN IN THE SCHEDULE AS BEING INCLUDED AND FOR WHICH PREMIUM HAS BEEN PAID. THE ASSURED MUST DISCLOSE TO THE UNDERWRITERS ALL FACTS, MATTERS AND CIRCUMSTANCES MATERIAL TO THIS POLICY, INCLUDING, BUT NOT LIMITED TO WHETHER THE ASSURED ENGAGES IN ANY OCCUPATION, SPORT OR PASTIME OR OTHER ACTIVITY OF A HAZARDOUS NATURE. We The Underwriters hereby agree with the Assured, to the extent and in the manner herein provided, that if the Assured sustains Bodily Injury caused by an Accident the Underwriters will pay to the Assured, or to the Assured's Executors or Administrators, according to the Schedule of Benefits after the total claim shall be substantiated under this Policy Provided Always That: 1. a) benefit shall not be payable under more than one of the items of the Schedule of Benefits in respect of the consequences of one Accident, except for any benefit payable hereunder in respect of Temporary Total Disablement, and b) no weekly benefit shall become payable until the total amount thereof has been ascertained and agreed. Where any payment is made for weekly benefit, the amount so paid shall be deducted from any lump sum subsequently payable in respect of the same Accident. 2. the total sum payable under this Policy in respect of any one or more claims shall not exceed in all the largest benefit under any one of the items contained in the Schedule of Benefits. 3. if Item 1 of the Schedule of Benefits is not covered, then no claim shall be payable, other than for weekly benefits, in respect of any Accident which would have given rise to a claim for death had that item been covered. 4. if Item 1 of the Schedule of Benefits is covered and an Accident causes the death of the Assured within twelve (12) months following the date of the Accident and prior to the definite settlement of the benefit for disablement provided for under Items 2 to 7 of the Schedule of Benefits, there shall be paid only the benefit provided for in the case of death. DEFINITIONS In this Policy: 1. 'BODILY INJURY' means identifiable physical injury which a) is caused by an Accident, and b) solely and independently of any other cause, except sickness directly resulting from, or medical or surgical treatment rendered necessary by such injury, occasions the death or disablement of the Assured within twelve (12) months from the date of the Accident. 2. 'ACCIDENT' means a sudden, unexpected, unusual, specific event which occurs at an identifiable time and place during the Period of Insurance. Page 1 of 4
Accident shall also include a) exposure resulting from a mishap to a conveyance in which the Assured is travelling; b) disappearance. If the Assured is not found within twelve (12) months of disappearing, and sufficient evidence is produced satisfactory to the Underwriters that leads them inevitably to the conclusion that the Assured has sustained Bodily Injury and that such injury has caused the Assured s death, the Underwriters shall forthwith pay any death benefit, where applicable, under this Policy, provided that the person or persons to whom such sum is paid shall sign an undertaking to refund such sum to the Underwriters if the Assured is subsequently found to be living. 3. 'TEMPORARY TOTAL DISABLEMENT' means disablement which entirely prevents the Assured from attending to their business or occupation. 4. 'PERMANENT TOTAL DISABLEMENT' means disablement which entirely prevents the Assured from attending to any business or occupation for which they are reasonably suited by training, education or experience and which lasts twelve (12) months and at the end of that period is beyond hope of improvement. 5. 'LOSS OF A LIMB' means permanent loss by physical separation of a hand at or above the wrist or of a foot at or above the ankle and includes permanent total and irrecoverable loss of use of hand, arm or leg. 6. 'AIR TRAVEL' means travel by the Assured as a passenger riding in, or boarding or disembarking from any aircraft with a current and valid standard airworthiness certificate. The aircraft must be operated by a pilot with a current and valid pilot s certificate with a proper rating to pilot such aircraft. 'AIR TRAVEL' does not include the Assured acting as a pilot, student pilot or crew member on any aircraft or the Assured having duties on or relating to the aircraft or flight. EXCLUSIONS This Policy does not cover claims in any way caused or contributed to by: 1. sickness or disease (except bacterial infection arising from Bodily Injury) or mental infirmity or emotional or psychological trauma; 2. war, whether war be declared or not, hostilities or any act of war or civil war; 3. the actual or threatened malicious use of pathogenic or poisonous biological or chemical materials; 4. nuclear reaction, nuclear radiation or radioactive contamination; 5. riding or driving in any kind of race; 6. the Assured engaging in or taking part in armed forces service or operations; 7. travel or flight in any aircraft or aerial device except for Air Travel as defined in this Policy; 8. the Assured s suicide or attempted suicide or intentional self-injury or the Assured being in a state of insanity; 9. the Assured s voluntary exposure to unnecessary danger (except in an attempt to save human life); 10 the Assured committing or attempting to commit a criminal act; Page 2 of 4
11. (a) any drug taken, administered or injected, except on the advice of or as directed by a licensed physician; (b) any alcoholic beverage consumed by the Assured to the level of intoxication; (c) any poison, chemical compound, gas or fumes voluntarily taken, administered, absorbed or inhaled; 12. pregnancy or childbirth; 13. neuroses, psychoneuroses, psychopathies or psychoses, anxiety, stress, fatigue or mental or emotional diseases or disorders of any type. CONDITIONS 1. The Underwriters will not be bound by an assignment either of this Policy or of any claim under this Policy unless they receive a written assignment before they pay the benefits claimed. The Underwriters will not be responsible for the validity of any assignment. 2. Notice of any change in the Assured s occupation must be given to the Underwriters as soon as practicable. The Underwriters will acknowledge such change of occupation in writing and make whatever change in Policy conditions and terms the Underwriters may require. Failure to notify the Underwriters of such change of occupation may result in a reduction of benefit as a result of any Accident arising out of or in the course of that occupation. 3. If the Assured shall regularly engage in any occupation, sport, pastime or other activity in which materially greater risk may be incurred than previously disclosed in connection with this Policy without first notifying the Underwriters and obtaining their written agreement to the inclusion under this Policy, (subject to the payment of any additional premium as the Underwriters may reasonably require as the consideration for such agreement), then no claim shall be payable in respect of any Accident arising from such activity. 4. Unless otherwise declared and agreed by the Underwriters no benefit will be payable for any condition for which the Assured has sought advice, diagnosis, treatment or counselling or of which the Assured was or should reasonably have been aware at inception of this Policy or for which the Assured has been treated at any time prior to inception. 5. Written notice of a claim must be given to the Underwriters within thirty (30) days after an Accident which causes or may cause a loss covered by this Policy, or as soon thereafter as reasonably possible. Notice given by the Assured or the Assured s representative to the Underwriters representative as stated in the Schedule, with sufficient information to identify the Assured and a brief description of the Accident, shall be deemed notice to the Underwriters. The Underwriters will send the Assured or the Assured s representative proof of loss forms after the Underwriters have received written notice of a claim. All medical records, notes and correspondence referring to the subject of a claim or a related pre-existing condition shall be made available on request to any medical adviser appointed by or on behalf of the Underwriters and such medical adviser shall, for the purpose of reviewing the claim, be allowed so often as may be deemed necessary to make an examination of the Assured. In the event of the Assured s death, the Underwriters have the right to have the Assured s body examined and to have an autopsy performed unless prohibited by law. 6. Proof of loss forms must be completed and given to the Underwriters within ninety (90) days of the Accident. 7. Any fraud, concealment, or deliberate mis-statement either in the proposal on which this Policy is based or in relation to any other matter affecting this Policy or in connection with the making of any claim hereunder shall render this Policy null and void and all claims hereunder shall be forfeited. 8. This Policy is subject to the law as stated in the Schedule. Page 3 of 4
9. All benefit payments under this Policy will be made in the United States of America in the currency of the United States of America. 10. No action on this Policy may be brought until sixty (60) days after written proof of loss has been given to the Underwriters, and any action must be started within three (3) years of the date the written proof is required to be submitted. If the law of the state where the Assured resides makes this time limit void, then an action must begin within the shortest time permitted by law. 11. In the event of the Underwriters failure to pay any amount claimed to be due under this Policy, at the Assured s request or the request of the Assured s representative, the Underwriters will submit to the jurisdiction of a Court of competent jurisdiction within the United States of America. Nothing in this paragraph constitutes or should be understood to constitute a waiver of the Underwriters right to commence an action in any Court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another court as permitted by the laws of the United States or of any State in the United States. In any suit instituted against the Underwriters on this Policy, the Underwriters will abide by the final decision of the Court or of the Appellate Court in the event of an appeal. The Underwriters representative named in the Schedule is authorized and directed to accept service of process on the Underwriters behalf in any such suit and, upon the Assured s request or the request of the Assured s representative, to give a written undertaking to the Assured that he or she will enter a general appearance on the Underwriters behalf. Further, pursuant to the statute of any state, territory or district of the United States which so provides, the Underwriters designate the Superintendent, Commissioner, or Director of Insurance or other officer specified for that purpose in the statute, or his successor or successors in office, as the Underwriters true and lawful attorney upon whom may be served lawful process in an action arising out of this Policy instituted by the Assured or on the Assured s behalf. The Underwriters designate their representative named in the Schedule, to whom the officer is authorized to serve process. 12. If, on the effective date of this Policy, any provision in it conflicts with the laws of any state which are applicable to this Policy, that provision is amended to meet the minimum requirements of such laws. Page 4 of 4
The Table of Syndicates referred to in the Policy follows:-
One Lime Street London EC3M 7HA