# AUTOMOBILE MEDICAL PAYMENTS INSURANCE COVERAGE PART

**POLICY NO:** 86-68-700  
**EFFECTIVE DATE:**  
**AGENCY NO.:**  

## SCHEDULE

### DESIGNATION OF AUTOMOBILES—Division 1 (Check appropriate box)
(1) Any owned automobile  
(2) Any hired automobile  
(3) Any licensed owned private passenger automobile  
(4) Any automobile described in the automobile schedule and designated "M.P."  
(5) Any non-owned automobile  
(6)  

### DESIGNATED PERSON INSURED—Division 2

#### ADVANCE PREMIUM
$  
$ INCL. IN COMPOSITE RATE  
$  
$  
Total Advance Premium $ INCL. IN COMPOSITE RATE

## I. COVERAGE F—AUTOMOBILE MEDICAL PAYMENTS

The company will pay all reasonable medical expense incurred within one year from the date of the accident.

### Division 1.
To or for each person who sustains bodily injury, caused by accident, while occupying a designated automobile which is being used by a person for whom bodily injury liability insurance is afforded under this policy with respect to such use.

### Division 2.
To or for each insured who sustains bodily injury, caused by accident, while occupying or, while a pedestrian, through being struck by a highway vehicle.

### Exclusions
This insurance does not apply:
(a) To bodily injury to any person or insured while employed or otherwise engaged in duties in connection with an automobile business, if benefits therefor are in whole or in part either payable or required to be provided under any workmen's compensation law.
(b) To bodily injury 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.
(c) Under Division 1, to bodily injury to any employee of the named insured arising out of and in the course of employment by the named insured, but this exclusion does not apply to any bodily injury arising out of and in the course of domestic employment by the named insured unless benefits therefor are in whole or in part either payable or required to be provided under any workmen's compensation law.
(d) Under Division 2, to bodily injury sustained while occupying a highway vehicle owned by any insured, or furnished for the regular use of any insured by any person or organization other than the named insured.

## II. PERSONS INSURED—DIVISION 2

Each of the following is an insured under this insurance to the extent set forth below:
(a) Any person designated as insured in the schedule;
(b) While residents of the same household as such designated person, his spouse and the relatives of either; and if such designated person shall die, any person who was an insured at the time of such death shall continue to be an insured.

## III. LIMIT OF LIABILITY

The limit of liability for Automobile Medical Payments Coverage stated in the declaration is applicable to each person is the limit of the company's liability for all medical expenses for bodily injury to any person, including any insured, as the result of any one 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.

## IV. ADDITIONAL DEFINITIONS

The additional definitions applicable to automobile bodily injury liability insurance also apply to this insurance, and when used in reference to this insurance, including endorsements forming a part of the policy.

"Designated automobile" means an automobile designated in the schedule and includes:
(a) An automobile not owned by the named insured while temporarily used as a substitute for an owned automobile designated in the schedule when withdrawn from normal use for servicing or repair or because of its breakdown, loss or destruction; and
(b) A trailer designed for use with a private passenger automobile, if not being used for business purposes with another type automobile and if not a home, office, store, display or passenger trailer.

"Highway vehicle" means a land motor vehicle or trailer other than:
(a) A farm type tractor or other equipment designed for use principally on public roads, while operated upon public roads; or
(b) A vehicle operated on rails or crawler treads, or
(c) A vehicle while located for use as a residence or premises.

"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.

"Occupying" means in or upon or entering into or alighting from.

## V. POLICY PERIOD; TERRITORY

This insurance applies only to accidents which occur during the policy period within the territory described in paragraph (1) or (2) of the definition of "policy territory."

## VI. ADDITIONAL CONDITIONS

A. 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 to physical examination by physician selected by the company as often as may be required. The company may, with the injured person or any person or organization rendering the services under this payment shall not reduce the amount payable hereunder for such injury. Payment hereunder shall not constitute an admission of liability of any person or entity thereunder, or the company.

B. Excess Insurance
Except with respect to an owned automobile, the insurance under Division 1 shall be excess insurance over any other valid and collectible automobile medical payments or automobile medical expense insurance.

The insurance under Division 2 shall be excess insurance over any other valid and collectible automobile medical payments or automobile medical expense insurance available to the insured under any other policy.

Form No. C79
IBM 062359