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LIFE ACCIDENT INSURANCE CLAUSE

 

GENERAL PROVISIONS

Article1 Composition of the Insurance Contract

The insurance contract (hereafter “Contract”) consists of the insurance policy, attached clauses, endorsements, amendments, application form(s), insurance application documents, statements, and other relevant written agreements.

Article2 the Insured

The Insured should be any natural person who travels by the public transportation, or drives or travels by a vehicle running for no business operational purpose.

Article3 the Applicant

The Applicant should be either the same as the Insured who proves to have the full capacity for civil conduct or such other person who has insurable interest on the Insured.

 Article4 the Beneficiary

1. Death Beneficiary

The insured person or applicant can designate one or several persons as the beneficiary of death benefit, and should designate the sequence of beneficiary or share of the sum assured, or all the beneficiaries have the equal right in the event of a claim. The designation of the beneficiary of the death benefit by the applicant shall be subject to the approval of the insured.

In the event of the death of the insured, the benefit shall be handled as inheritance of the insured and payable to the insured’s heir(s) according to Republic of China Law of Succession under one or more of the following circumstances:

(I) No beneficiary is designated either by the applicant or the insured.

(II) The beneficiary predeceases the insured and no other beneficiary is designated.

(III) The beneficiary gives up the right to receive the benefit of this contract or is deprived of the right to receive the benefit of this contract as per the law and no other beneficiary is designated.

Where the beneficiary and the insured decease in the same incident and no deceased sequence can be determined, presumption shall be made that The beneficiary predeceases the insured. The insurer does not assume any legal disputes as a result of changes in insurance beneficiary.  

In case the insured or the applicant changes the beneficiary of the death benefit, the insurer shall be notified in written, and the insurer shall endorse on this contract. The change of the beneficiary of the death benefit by the applicant shall be subject to the written approval of the insured or the guardian of the insured.

2. Disability Beneficiary

Unless stipulated otherwise, the beneficiary of disability is the insured person himself

INSURANCE COVERAGE

Article5

1. During the period of insurance, the Insurer shall bear such insurance liability to the Insured according to the agreement concluded with the Applicant as for any one or several types of risks out of the following six types of risks as listed below:
Type A: The Insured suffers any accidental injury in a vehicle he/she drives for no business operational purpose;
Type B: The Insured suffers any accidental injury in a vehicle legally driven by another person for no business operational purpose when traveling by such vehicle;
Type C: The Insured suffers any accidental injury in a passenger vehicle when traveling by such vehicle as a passenger;
Type D: The Insured suffers any accidental injury in a railway transportation car when traveling by such railway transportation as a passenger;
Type E: The Insured suffers any accidental injury during the period starting from his/her stepping onto the deck till he/she leaves the passenger ship when traveling by such ship as a passenger;
Type F: The Insured suffers any accidental injury during the period starting from his/her passing through the airport security check till he/she leaves the cabin door of the civil aviation flight when traveling by such flight as a passenger.

 2. If the insured person encounters the above accident during the period of insurance, the insurer shall pay the following benefits:

1. Death Benefit

In case that the accidental injury sustained by the insured person directly results in death within 180 days from the date of the accident, the insurer shall pay the sum assured stated in this contract as the death benefit.

The insurer shall pay the death benefit likewise in case that the insured is declared to be death for disappearance resulted from the accident, natural disaster. However if the Insured is discovered to survives after being declared dead, any death benefit paid should be returned to the insurer by the benefit receiver within 30 days from the date of knowing or being reasonably assumed to have the knowledge of the fact that the insured is still alive.

Disability benefit shall be deducted from the death benefit if it has been paid in advance.

2. Disability Benefit

If the accidental injury sustained by the insured person directly results in any disablement stated in “the personal insurance disablement benefits table” within 180 days from the date of the accident, the insurer shall pay the disablement benefits in accordance with the relevant of the percentage of the sum insured per the level of disablement stated in the above schedule. If the treatment has not completed in 180th day after the occurrence of accident, the insurer shall make an evaluation of the status of the insured person on that day and pay the benefit accordingly.

In case of multiple disablements resulted from one single accident, the insurer shall pay the total sum of each disability benefit. However, if the multiple disabilities are sustained by the same hand or same foot, only one disability benefit shall be payable. And in such case the insurer shall pay the highest disability benefit.

In case of disablement resulted from current insured accident will results in a higher disablement degree stated in “the personal insurance disablement benefits table” together with pre-injury, the insurer shall pay disability benefit in accordance with the higher degree. However benefit for pre-injury shall be deducted from the death benefit if it has been paid in advance. .

3. Burn Benefit
Where the Insured gets burnt up to Grade III due to any accidental injury and the burn area reaches any one of such burn areas as specified in the Life Insurance Burn Benefits Table (Table 2), the Insurer shall pay the burn benefits in accordance with the relevant of the percentage of the sum insured per the level of burn stated in the above table.
In case of multiple burns resulted from on single accident, the Insurer shall pay the total sum of each burn benefit, which total sum, however, shall not exceed such accidental injury sum insured of the Insured corresponding to such type of risk as specified in the Policy.

4. The total amount of benefits to be payable by the Insurer under Article II hereof to each and every Insured who suffered any one of such risks as agreed upon application for the insurance shall be limited to the sum insured of the Insured corresponding to such type of risk; the insurance liability borne by the Insurer to the Insured for such types of risks shall terminate when the benefit as paid either in a lump sum or accrued has reached the sum insured of the Insured corresponding to such type of risk.

EXCLUSIONS

Article 6 In case of one of the following conditions, due to which the insured has deceased, disabled, the insurer shall not undertake pay any indemnification of benefit:

1.         Deliberate killing or injury to the insured by the applicant;

2.         Suicide, self-inflicted injury by the insured, but not including the suicide by those who are incompetence;

3.         Fighting, being attacked or being murdered caused by the insured;

4.         Injury caused by the insured’s disease, abortion or parturition which is non-accidental;

5.         Injury caused by orthopedic surgery or treatment, cosmetic surgery or drug allergy and/or any medical treatment.

6.         The insured takes, applies, or injects prescription drugse against the doctor's instructions;

7.         The insured is declared to be death for disappearance resulted from certain event other than an accident, natural disaster;

8.         The insured engages in sports with high risks such as diving, parachuting, climbing, expedition, martial arts competition, wrestling competition, stunts, horse and automobile racing and any other high-risky sports;

9.         The insured violates the law, commits crime intentionally or resists to arrest;

10.      Failure of the Insured to comply with the applicable safety regulations on either driving or traveling by vehicles;

11.      Any injuries suffered by the Insured due to any accident as a result of overloading of the vehicle he/she was driving;

12.      The Insured is engaged in the various vehicle shows, races or drills, which are deemed to be of highly risky sports or activities;

13.      Expolsion , radiation, pollution, or burn by nuclear energy, atomic energy, biologic or chemic weapon.

14.      Terrorism

Article 7 The Insurer shall not undertake to pay any indemnification for any injury occurred In case of one of the following conditions:

1.         Mental insanity or disorder of the Insured Person;

2.         War, military action, civil commotion, or armed rebellion;

3.         Accidents caused by the insured under the influence of alcohol, drug or controlled medicine;

4.         The insured drives after alcoholic drinking, or drives without a driver’s license or without a valid driver’s license, or he/she drives a motor vehicle which doesn’t have a valid vehicle license.

SUM INSURED AND PERMIUM

Article 8 The total amount benefit payable to any individual insured person is limited to the sum assured which shall be decided upon agreement between the Applicant and the Insurer and specified in the Insurance Contract. Once decided, the sum insured is unchangeable during the insurance term.

PERIOD OF INSURANCE

Article 9 Insurance period of this contract is one year from 0:00 of the starting date of insurance liability to 24:00 of the expiry date of insurance liability as specified in the Insurance Contract.

OBLIGATIONS OF THE INSURER

Article 10 In case of application of standard clauses, the Insurer shall enclose them in the Proposal Form and explain the contents of the insurance contract to the Applicant. For the clauses exempting the Insurer’s liability, the Insurer shall make remarkable notice in the Proposal Form, Policy or other certificates to draw the Applicant’s attention, and explain them clearly in written or oral form when entering into the contract. Otherwise, such clauses shall be void.

Article 11 The Insurer shall issue the Policy or other certificates in a timely manner after the establishment of an insurance contract

Article 12 The Insurer’s right to cancel the Contract as stated in the wording is void if not exercised by the Insurer within thirty days after his acknowledgement of any causes for cancellation of this contract.

If before the establishment of the insurance contract, the Insurer is aware of the Applicant’s misrepresentation or non-disclosure, the Insurer cannot cancel the contract, and still shall be liable for Damage insured by this contract.

Article 13 If the Insurer believes that the proofs and documents provided by the Insured, as required in, are not sufficient, the Insurer shall request the Applicant and/or the Insured to provide additional materials in time and once for all.

Article 14 Upon receipt of a claim, the Insurer shall confirm whether the Damage is covered by this contract or not in a timely manner.  For complicated cases, the Insurer shall make decision   within thirty days, unless otherwise stipulated in the insurance contact.

The Insurer shall notify the Insured of the decision in a timely manner. If the Damage is covered by this contract, the Insurer shall make payment within ten days after reaching an agreement with the Insured. If the time limit for indemnity is specifically stipulated in the insurance contact, the Insurer shall make payment within such time limit. If the Damage is not covered by this contract, within three days after the decision, the Insurer shall issue a declination letter and explain the reasons to the Insured.

Article 15 The Insurer shall allow an advance payment that can be determined by the available proofs or documents if the final settlement amount cannot be determined within sixty days after receipt of such claim and relevant documents, and pay the balance to the Insured after the final amount of indemnity is adjusted.

OBLIGATIONS OF THE APPLICANT AND/OR INSURED

Article 16 Unless specified otherwise, the insurant shall pay in a lump sum before the contract takes effect. The Company is not liable for any liability until the premium is made as required by the insured.

Article 17 If the Insured conceals facts deliberately or fails to perform the duty of disclosure due to gross negligence that would be enough to affect the Insurer from making the decision of whether or not to agree to accept the insurance or to raise the premium rate, the Insurer has the right to     terminate the contract.

If the Insured deliberately refuses to perform the duty of disclosure, the Insurer shall not undertake to pay indemnity or insurance money for insured accident that occurs before the contract is terminated and shall not return the insurance premium.

If the Insured fails to perform the duty of disclosure due to gross negligence, thereby seriously affecting the occurrence of insured accident, the Insurer shall not undertake to pay indemnity or insurance money for the insured accident that occurs before the contract is terminated but shall return the insurance premium.

Article 18 The Applicant should duly notify the insurer in writing of any change in residence or mailing address. If the Applicant fails to inform the insurer in writing, documents will be delivered to the latest recorded address in the Contract.

Article 19 The Applicant should duly notify the insurer in writing of any change in the insured member, the insurer shall issue an endorsement upon agreement.

1.                   If the insured is to be increased, the aplicant should notify the insurer in writing and fill in the change application. The insurer starts to be liable for the new insured after it has approved the application and collected the premium.

2.                   If the insured is to be reduced, the insurer’s liability towards the mentioned insured shall cease from the date when the application is approved. The insurer shall return the unearned premium less handling charge to the applicant.

3.                   If the number of insured under the coverage of this contract is less than the minimum requirement as specified in the contract, the insurer has right to cease the insurance contract while refunding the unearned premium less handling charge accordingly.

Article 20 In the event of the insured accident, the insured shall notify the Insurer in a timely manner. The Insurer shall not undertake to pay any indemnification for any such undeterminable part of the insured accident as of which the nature, causes and losses etc. can hardly be determined due to either willful reluctance or failure of the Insured to give such notice in a timely manner though in absence of any material misconduct, unless, however, the Insurer has otherwise promptly known, or shall have promptly known, of the occurrence of such insured accident.

However, Delayed Notification due to force majeure will be acceptable by the insurer.

CLAIMS AND PAYMENT OF BENEFIT

Article 21 In the event of accident, the applicant of the benefit shall fill in the Benefit Claim as the claimant and provide the documents as follows. The insurer shall not assume the liability towards the insured without the following documents.

1. Claims for death benefit

1.1 Requisition for death benefit

1.2 Insurance policy and Certificate issued by the insurer;

1.3 ID Card of the applicant of the benefit;

1.4 Death Certificate and Household Registration Cancellation Certificate issued by Public Security Department, or medical institutions recognized by the insurer. If the insured is declared death on account of an accident or natural disaster, the beneficiary is required to provide Death Declaration issued by the People’s Court;

1.5 Accident certificate issued by public security department Chinese embassy settled in that country;

1.6 Other certificates and documents provided by the applicant of the benefit that can be used to identify the nature, cause and seriousness of the event insured against.

1.7 If the applicant of the benefit has entrusted other person to handle the claim, the trust deed together with ID Cards of both the insured and the entrusted person are required.

2. Claims for disability or burn

2.1 Requisition for death benefit

2.2 Insurance Policy and Certificate issued by the insurer;

2.3 The ID Card of the applicant of the benefit;

2.4 Disablement evaluation certificate issued by the approved medical or judicatory institution.

2.5 Accident certificate issued by public security department Chinese embassy settled in that country;

2.6 Other certificates and documents provided by the applicant of the benefit that can be used to identify the nature, cause and seriousness of the event insured against.

2.7 If the applicant of the benefit has entrusted other person to handle the claim, the ID Cards of both the insured and the entrusted person are required.

LIMITATION OF ACTION

Article 22 The Insured shall have a 2-year valid litigation term to raise claims to the Insurer for indemnities, which term shall commence as of the date when he/she has known or should have known of any such insured accident as occurred.

DISPUTE RESOLUTION AND JURISDICTION

Article 23 All disputes arising from implementing this Contract shall be settled through negotiations between the parties concerned. Upon failure to reach an agreement through negotiations, such dispute shall be referred to the arbitration commission specified in the contract. If there is no arbitration commission specified in the contract and no agreement reached for arbitration, legal proceeding could be initiated with the People’s Court in People’s Republic of China.

Article 25 All disputes related to this insurance contract shall be governed by the laws of the People’s Republic of China, but except laws of Hong Kong SAR, Macau SAR, and Taiwan.

MISCELLANEOUS

Article 26 After the establishment of an insurance contract, the applicant may notify the insurer to cancel the Contract in writing, unless benefit has been claimed.

In the event of cancellation, the applicant of the benefit shall fill in the Benefit Claim as the claimant and provide the documents as follows,:

1. Requisition for cancellation of the contract;

2. The original insurance contract;

3. Certificates of premium paid;

4. ID or certification of the applicant.

The insurance contract shall be terminated automatically form the date the insurer receive the requisition and the insurer shall refund the unearned premium within 30 days.

LANGUAGE

Article27 In the event of a discrepancy between the Chinese version and its English translation, the Chinese version shall prevail.

DEFINITIONS

Article28: Unless as otherwise set forth herein, the following terms as applied herein shall bear such meanings as given below:

Insurer: Refers to China Pacific Property Insurance Co., Ltd.

Accident: External, unexpected, unintentional, non-disease-related event that injuries the body of the insured.

Limbs： Refers to the four limbs of human body, namely the upper left limb, upper right limb, lower left limb and lower right limb.

Unearned net premium = Annual premium X (number of days of the remaining insurance period/number of days of the insurance period) X (1-20%)

Accumulated amount of indemnity refers to such total sum of indemnities including both those having been paid by the Insurer and those having not been paid despite the occurrences of the insured accidents within the actual insurance period, exclusive, however, the arbitration or litigation expenses for which the Insurer remains to be responsible.

The applicant of the benefit: Refers to either the heritor of the beneficiary or the insured or other natural person legally entitled to claim for the insurance benefit.

Force Majeure: Force majeure: Unpredictable, unavoidable, and irresistible forces.

Diving: Underwater activity in river, lake, sea, reservoir, canal, etc, by using special apparatus to help breathe.

Climbing: Climbing cliff, external wall of building, artificial cliff, ice cliff and ice mountain, etc.

Martial arts competition: Antagonistic sports such as Judo, Karate, Taekwon, free style fighting, boxing, and other antagonistic sports using weapons.

Expedition: Intentionally involving oneself in activities with known risk either threatens life or harms body under special natural conditions, such as river drifting, walking through dessert or primeval forest, etc.

Stunts: Special skills such as, but not limited to, horse riding, acrobatics, and animal training, etc.

Burns: refer to any such burns of the human body soft tissues as suffered by the Insured due to any accident during the period of insurance, with the degree of burn having reached Grade III, which is judged by such standard as the injuries of the whole skin layers (including epidermis and hypodermis) involving necroses, scabbing and eventual falling apart of muscles, bones and soft tissues. The degrees of burns and calculations of burn areas shall be subject to the appraising results issued by such appraising institute as recognized by the Insurer.
Motor Vehicles: The motor vehicles as referred to herein refer to those that are equipped with minimum four wheels, driven or drawn by power trains and validated for driving on road, excluding the railway transportation vehicles and tractors etc. for agricultural purposes.
Passenger Vehicles: refer to those vehicles that are licensed to do passenger transportation business under registrations with the competent governmental authorities.
Railway Transportation Vehicles: refer to those vehicles that are licensed to do passenger transportation business under registrations with the competent governmental authorities, including trains, metro, light rail trains, trolleys, maglev trains and cable cars.
Passenger Ships: refer to those ships, including ferryboats, having a certified capacity of minimum 12 passengers, which are licensed to do passenger transportation business under registrations with the competent governmental authorities.
Civil Aviation Flights: refer to those civil aviation flights that are licensed to do passenger transportation business under registrations with the competent governmental authorities.
Body and four limbs.

 

 

Attachment 1

 

China Pacific Property Insurance Co., Ltd.

Life Insurance Disability Benefits Table

 

Class	Item	Degree of Disability	percentage of the sum insured
1	1 2   3   4   5   6 7 8	Loss of sight of both eyes.(Remark 1) Loss of both upper limbs above the wrist joint or of both lower limbs above the ankle joint. Loss of one upper limb above the wrist joint and of one lower limb above the ankle joint. Loss of sight of one eye and loss of one upper limb above the wrist joint. Loss of sight of one eye and loss of one lower limb above the ankle joint. Permanent and total loss of functions of joints of four limbs. (Remark 2) Permanent and total loss of ability of mastication (Remark 3). Permanent Total Loss of the central nervous system or the thorax and all abdominal organs resulting in the complete inability to engage in any job and the inability to carry out daily activities essential to life without the  assistance of others.(Remark 4)	100%
2	9     10	Permanent and total loss of functions of two out of three major joints on two upper limbs, two lower limbs or one upper limb and one lower limb. (Remark 5) Loss of ten fingers.(Remark 6)	75%
3	11   12   13 14 15	Loss of one upper limb above the wrist joint or permanent and total loss of functions of the three joints of one upper limb. Loss of one lower limb above the ankle joint or permanent and total loss of functions of the three joints of one lower limb. Permanent and total loss of hearing in both ears. (Remark 7) Permanent and total loss of functions of ten fingers.(Remark 8) Loss of ten toes.(Remark 9)	50%
4	16 17   18   19   20 21 22	Loss of sight of one eye. Permanent and total loss of the functions of two of three major joints of one upper limb. Permanent and total loss of the functions of two of three major joints of one lower limb. Loss of four fingers of one hand with the thumb and the index finger included. Permanent shortening of one lower limb by more than 5 centimeters. Permanent and total loss of speech. (Remark 10) Permanent and total loss of the functions of ten toes.	30%
5	23   24   25 26 27 28 29	Permanent and total loss of the functions of one of three major joints of one upper limb. Permanent and total loss of the functions of one of three major joints of one lower limb. Loss of thumb of both hands. Loss of five toes of one foot. Significant injury to eyelids of both eyes. (Remark 11) Permanent and total loss of hearing in one ear. Nose injury with permanent impediment to the smelling function of the nose. (Remark 12)	20%
6	30   31   32	Loss of the thumb and index fingers of one hand or of any three fingers with thumb or index finger included. Permanent and total loss of functions of any three fingers of one hand with the thumb or the index finger included. Permanent and total loss of the functions of five toes of one foot.	15%
7	33   34	Loss of a thumb or an index finger or any two of the other fingers of one hand. Permanent and total loss of the function of the thumb and the index finger of one hand.	10%

 

REMARKS:

1.      Loss of sight shall mean loss or removal of eyeball, inability of distinguishing light and shade, or barely tell hand movement in front of eyes, with the best sight remaining after correction at 0.02 in the international standard sight schedule, or the sight scale less than 5 degrees, according to the diagnosis of qualified ophthalmologist.

2.      Loss of function of joint shall mean permanent stiffness, numbness or immobility of joint.

3.      Loss of ability of mastication (shall mean the loss of ability to take or swallow any food except liquid food due to the disability of chewing and swallowing resulted from physical or functional handicap other than the reason of teeth.

4.   Inability to carry out daily activities essential to life without the assistance of others shall mean that the activities such as food taking, urine or faces discharging, dressing or taking off clothes, general living activities, walking and taking a bath etc. cannot be accomplished without the assistance of others.

5.   The three major joints of the upper limb shall mean shoulder joint, elbow joint and wrist joint; the three major joints of the lower limb shall mean hip joint, knee joint and ankle joint. 

6.      Loss of finger shall mean severance at proximal interphalangeal joint of the finger (or at the interphalangeal joint of the thumb).

7.      Loss of hearing shall mean loss of average language frequency ability higher than 90 decibels, when tested with the frequency of 500, 1,000 and 2,000 Herts.

8.      Loss of function of finger shall mean severance through distal interphalangeal joint, or permanent immobility from proximal interphalangeal joint or joint immobility of the finger.

9.      Permanent total loss of toe shall mean severance through the metatarsal-phalangeal joint.

10.    Loss of speech shall mean disability of articulating of any three out of four language functions of labial sound, alveolar sound, palatal sound and valor sound; or aphasia resulted from brain injury diagnosed by the qualified E.N.T. medical doctor, but aphasia resulted from any mental handicap is excluded.

11.    Significant injury to lid of both eyes shall mean the eyelids could not completely cover the corneas when closing the eyes.

12.    Nose injury with permanent impediment to the smelling function of the nose shall mean loss of all or above 50% of nasal cartilage and incurable obstruction in two nasal canals and respiration difficulty, or loss of smelling function of two nasal canals.  

Permanent and total shall mean the situation that the function is still completely lost after 180 days of the date of accident, except for that of removal of eyeball and other apparent irrecoverable cases.   

 

Attachment 2

 

China Pacific Property Insurance Co., Ltd.

Life Insurance Burn Benefit Table