# Premises Medical Payments Insurance Coverage Part

**Policy No.:** BA 86-68-700  
**Effective Date:** [Not specified]  
**Agency No.:** [Not specified]

## Schedule

| Coverage | Advance Premium |
|----------|------------------|
| (a) Premises and operations | $ INCL. |
| (b) Elevators | $ |
| (c) Sports activities | $ INCL. |

Total Advance Premium: $ INCL.

## Composite Rate

### 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 occurrence, on account of such injury, provided such injury arises out of (a) conditions in the insured premises; (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:
1. To bodily injury:
   - Arising out of the ownership, maintenance, operation, use, loading or unloading of any elevator unless a premium charge is entered for elevators in the policy with respect to Premises Medical Payments Coverage.
2. Arising out of the ownership, maintenance, operation, use, loading or unloading of:
   - Any automobile or aircraft owned or operated by or rented or loaned to the named insured.
   - Any other automobile or aircraft operated by any person in the course of his employment by the named insured.
3. Arising out of the ownership, maintenance, operation, use, loading or unloading of any watercraft, if the bodily injury occurs away from the insured premises.
4. Arising out of and in the course of the transportation of mobile equipment by an automobile owned or operated by or rented or loaned to the named insured.

#### (b) To bodily injury:
1. Included within the completed operations hazard or the products hazard.
2. Arising out of operations performed by the named insured by independent contractors other than:
   - Maintenance and repair of the insured premises.
   - Structural alterations at such premises which do not involve changing the size of or moving buildings or other structures.
3. Resulting from the selling, serving or giving of any alcoholic beverage:
   - In violation of any statute, ordinance or regulation.
   - To a minor.
   - To persons under the influence of alcohol.
   - Which causes or contributes to the intoxication of any person; but this exclusion applies only if the named insured is a person or organization engaged in the business of manufacturing, distributing, selling or serving alcoholic beverages or is an owner or lessor of premises used for such purposes.
4. 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.
5. To bodily injury:
   - 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 foregoing, if the bodily injury arises out of and in the course of his employment therewith.
   - To any other tenant if the bodily injury occurs on that part of the insured premises rented from the named insured or to any employee of such a tenant.

#### Limits of Liability

The limit of liability for Premises Medical Payments Coverage stated in the declarations as applicable to "each person" is the limit of the company's liability for all medical expenses for bodily injury to any one person as the result of any one accident, but subject to the above provision respecting "each person". The company's combined Premises Medical Payments Coverage for all medical expenses for bodily injury to two or more persons as the result of a one accident shall not exceed the limit of liability stated in the declarations 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

- **"Insured premises":** Means all premises owned 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 expenses":** 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 examine the company to obtain medical reports and copies of records. The injured person shall submit physical examination reports selected by the company whenever so requested 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.

**Form No.:** C58  
**IBM 062356**