# Premises Medical Payments Insurance

## Coverage Part
**Premises Medical Payments Insurance**

**For attachment to Policy No. 32 78 678-00 to complete said policy.**

### Schedule
The insurance afforded is only with respect to the following Coverage indicated by specific premium charge or charges. The limit of the company's liability against such Coverage shall be as stated herein, subject to all the terms of this policy having reference thereto.

| Coverage | Limits of Liability | Advance Premiums |
|----------|---------------------|------------------|
| E—Premises Medical Payments | 10,000 dollars each person | 50,000 dollars each accident |
| (a) Premises and operations | $ INCL. IN | $ COMPOSITE |
| (b) Escalators | $ RATE | $ |
| (c) Sports activities | $ | $ |

Form numbers of endorsements attached at issue: **$**

Total Advance Premium: **$ INCL. IN**

### Composite Rate
foregoing if the bodily injury arises out of and in the course of his employment therewith:

(2) to any other tenant if the bodily injury occurs on that part of the insured premises leased from the named insured or to any employee of such a tenant if the bodily injury occurs on the tenant's part of the insured premises and arises out of and in the course of his employment for the tenant;

(3) to any person while engaged in maintenance and repair of the insured premises or alteration, demolition or new construction at such premises;

(4) to any person if any benefits for such bodily injury are payable or required to be paid under any workmen's compensation law, unemployment compensation or disability benefits law, or under any similar law;

(5) to any person practicing, instructing or participating in any physical training, sport, athletic activity or contest unless a premium charge is entered for sports activities in the policy with respect to Premises Medical Payments Coverage.

(d) to any medical expense for services by the named insured, any employee thereof or any person or organization under contract to the named insured to provide such services.

### I. Coverage E—Premises Medical Payments
The company will pay to or for each person who sustains bodily injury caused by accident all reasonable medical expense incurred within one year from the date of the accident on account of such bodily injury, provided such bodily injury arises out of (a) a condition in the insured premises or (b) operations with respect to which the named insured is afforded coverage for bodily injury liability under this policy.

### Exclusions
This insurance does not apply:
(a) to bodily injury:
(i) arising out of the ownership, maintenance, operation, use, loading or unloading of:
(ii) any automobile or aircraft owned or operated by or rented or loaned to any insured;
(iii) any other automobile or aircraft operated by any person in the course of his employment by any insured;
but this exclusion does not apply to the parking of an automobile on the insured premises, if such automobile is not owned by or rented or loaned to any insured.
(ii) arising out of the ownership, maintenance, operation, use, loading or unloading of:
(i) any mobile equipment while being used in any prearranged or organized racing, speed or demolition contest or in any stunting activity or in practice or preparation for any such contest or activity or
(ii) the operation or use of any snowmobile or trailer designed for use thereon;
(iii) arising out of the ownership, maintenance, operation, use, loading or unloading of:
(i) any watercraft owned or operated by or rented or loaned to any insured;
(ii) any other watercraft operated by any person in the course of his employment by any insured;
but this exclusion does not apply to watercraft while ashore on the insured premises; or
(iv) arising out of and in the course of the transportation of mobile equipment by any vehicle owned or operated by or rented or loaned to any insured;
(b) to bodily injury:
(i) included within the completed operations hazard or the products hazard;
(ii) arising out of operations performed for the named insured by independent contractors other than (i) maintenance and repair of the insured premises or (ii) filling in, grading, excavating, or similar work which does not involve changing the size of or moving buildings or other structures;
(iii) resulting from the selling, serving or giving of any alcoholic beverage (i) in violation of any statute, ordinance or regulation, (ii) to a minor, (iii) to a person who is intoxicated, or (iv) to a person whose intoxication contributes to the intoxication of any person, if the named insured is a person or organization engaged in the business of manufacturing, distributing, selling or serving alcoholic beverages or, if not so engaged, an owner, partner, officer, or agent of such persons but not only partly (i) of this exclusion (b); (d) applies when the named insured is such an owner or lessee;
(c) due to war, whether or not declared, civil war, insurrection, rebellion or revolution, or to any act or condition incident to any of the foregoing;
(d) to bodily injury:
(i) to the named insured, any partner therein, any tenant or other person regularly residing on the insured premises or any employee of any of the

### II. Limits of Liability
The limit of liability for Premises Medical Payments Coverage stated in the schedule as applicable to "each person" is the limit of the company's liability for all medical expense for bodily injury to any one person as the result of any one accident, but subject to the limits provided respecting "each accident", the total liability of the company under Premises Medical Payments Coverage for all medical expense for bodily injury to two or more persons as the result of any one accident shall not exceed the limit of liability stated in the schedule as applicable to "each accident".

When more than one medical payments coverage afforded by this policy applies to the loss, the company shall not be liable for more than the amount of the highest applicable limit of liability.

### III. Additional Definitions
When used in reference to this insurance (including endorsements forming a part of the policy):
"insured premises" means all premises owned by or rented to the named insured with respect to which the named insured is afforded coverage for bodily injury liability under this policy, and includes the ways immediately adjoining on land;
"medical expense" means expenses for necessary medical, surgical, x-ray and dental services, including prosthetic devices, and necessary ambulance, hospital, professional nursing and funeral services.

### IV. Policy Period, Territory
This insurance applies only to accidents which occur during the policy period within the United States of America, its territories or possessions, or Canada.

### V. Additional Condition
Medical Reports; Proof and Payment of Claim
As soon as practicable the injured person or someone on his behalf shall give to the company written proof of claim, under oath if required, and shall, after each request from the company, execute authorization to enable the company to obtain medical reports and copies of records. The injured person shall submit all medical reports and copies of records to the company promptly upon receipt as the company may reasonably require. The company may pay the injured person or any person or organization rendering the services and the payment shall reduce the amount payable hereunder for such injury. Payment hereunder shall not constitute an admission of liability of any person or, except hereunder, of the company.

**[Authentic]**