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001' '1 OOOOliOO\,''''b.' U. "UICIIW/tlll;4""
JOAN L, AU)(ANOI".
Pl,lnt'"
IN TM' COU"T 0' COMMON '\fAt Of
CUMlI'U.ANO COUNTY, ,.NNIVLVANIA
NO. ...20. CIVI\. Tl"M
CIVIL ACTION. l.AW
v,
CUNA MUTUAL INIU"ANce O"OUI'.
O.f'ndlnl
NOTtel 0' A""T"ATO"" HlA"ING
TO; John H, 11011101. hquil'
1I000jo.. 0""" . Houllon
.. NOlin HanovII '111.1
e,lUII,,'A 17013
J,m'I', l)'Ant.,o. "quill
MeN.... WtllH' . Nutlek
tOO"'" '11'"
,. O. 101( "..
H.,rl.bwg.'A UtOI-t1"
AND NOW. IN, 22nd eI,y of Olftnl"f, ,It.. '10\1 II' /'IIf'by notlfltG 'MIIM Ifb/IIIIOI'
IPPolnl.d In til, Ibov"4'P(JOIIId ICfl(lift will MId , Mlrlflg fff Iht WlatO" of lhfl, ."OInlm.nl II
Ivllow.:
01111
'fIlM I
',lifilffY 2. , "'
t:30 11m,
Till I.w offiC" of JoM'on, O~tt", I"wlf' . w~a",(. '0' Mllk'IIII"1. i
L.tnovfllI. ',MlylV.1lJ1
"Hau.nl
CA VIA r: THOll 'A"TIII WI.ttlNQ TO INT"ODUCI VloeOT An eVIDINce WI" L IIU"CTfD TO
"A VI WI NlC.IIAftY COU""'NT TO l)t.,LAY THI VIOIOTA'I ''''UNf AT THI A"'ITRATlON
LOCATION, ,u"n""~O"t. IN nf' IVINT "fAl OC'OIITlON. A"I TO It UItO A' eVIDeNCt,
'"ANIC""TI'HOULD II ""OVIOtO ,Oft ADVANC' ",view TO ntl AftIJTftATO".,
'AlHlII WI,H'NO TO ""QUI UOA~ ,gfNU WlH II lX,eCJfD TO ""VI CO"',, Of
n AU"It, CAin. nc, WffH "&LeVANT '0""ON8 tttQHUOHUO "", tACH """TIIATOI'I ANO
()i"O'fHQ c;OUHtU AT HII C:OMMINCIMINJ 0' WI 'f""l/N(I. I
/. I, 'I/'~"" t It
",/J,~~?r .
c:'~yW~:'1;:'-: .!i.iH.:'Cr..iI...'. ".~, I
0.",1( Wti'ft fMW'. A,liittfl{i!' i
~~ t Wi'~ fMVi#" A*tl'll'f j
f.i-t4... W_t f~.
"",..w ~ .~, t~.
{',>\Af A"'''''''tt'i'l~
j;,;I1."" ~" "'fr>t~.f~.', o,"~.
.
CUMA MUTUAl INSUWCl ~Il JY
5910 Mln.rll Point Mo.d '{/
Mldl,on, WI,con,ln .)10'
Group Poltcy N~rl
Pollc:yhold.rl
Poltcy Olt.1
Delivered In ,ute ort
Thh Policy II IIIu.d In con,ld.r.tlon of the Application fDr th. PolicY
Ind the plyment of the pr.mlum wh.n It I, du.. thl' PolIcy provld..
Inlur.nc. for Iccld.ntl' d..th Ind dl...mb.~nt of th. In'ur.d '.r.on .nd
thl In,urld Dlp.ndlnt" If Ipp'lclb'..
Thll Po'lcy tlk., .ff.ct on the Po'lcy Olt.. th. ,.ctlon, 'II 'orth on Ih.
fol'owlng pig'. .r. plrt of thl' Po'lcy. Thll Polley I' gow,rn.d by Ih.
Ilw' 0' the .tlt. In which It II d.llv.r.d,
CUNA MUtUAL INSUlIAHCt somn
,__ ff't~::'L'i' 4If\I''''(.~
\\', ,oJ,: . I . r,
~I.';: ". .
pr..1 d.nt
JU~ 18 'M6
GBOllP Po t. I'
lI.tslJnM ICE l'l[ .'At" Mt' !'II
lSTA n: 01' wl~r.(M)'"
Ster.tary
GROUP ACCIDENTAL DtAtH I DI~IRMl"t POLICY
Tlb'. of Cont.nt,
T'rMa .nd D,'lnl)lonl
fen,ra' Provl,lon'
"n.ft tI
hel",lon,
T,rwlnUlolI of Indhldu.1 11I,,,raIlCl
How to '1" . Clal.
'r.ml". Chlrg" .nd "ymlnt
T,rmln.tlon of thl' Po'lcy
I
)
.
.
,
.
.
.
Notle. to Pollcyhol4tr'
Th' Socl,ty wl'l hold e '1,""lel G'ntr.' El,ctlon In "edllon, Wlleon,ln In
,ech .v.n."~.rld Yler 'or tht .I,ctlon of Ol',ctor, .04 ,"y oth,r ..It."
to be e",ov,d by poIICybold"', It will b. btld Oil th, third W,dAf'-'y 0'
April b,lw,,1I th, hov', 0' 10:00 .... end ':00 p... unl." pollcyhol",.
.,. otAf,.II. not'fl,d.
If YOII Will. 'H. . ...IIC1t t\l ul.. pl,nl writ. (UlIA "'filiI 111111"1\('
~".t1, UIO HI,.."I h'"t .il.d, '.0. ... nl. ",dllOlI, VIU.",III Ul01 It
1,,'1 10 d.y' III .4.."(,,
'\ . '..i
TtRMS . DEfiNITIONS
~s uI.d In thll Poltcy th.l. wordl .nd t.,.s Ih.ll hlv. the followIng
nMllnlngl1
CERTIfICATE
..Inl the C.rtlflc.t. of Inlurlnc. Illu.d to .
perlon Insured under thll PolIcy.
..Inl (I) the Ellglbl. "'-b.r'l IpOUI. who ts und.r
6' Y'lrl of .g'l .nd 12) the Ellllbl. M.mb.r'a
unMirrl.d d.p.ndent chI dr.n und.r I y..ra of ag..
Ellglbl. D.p.ndent .lso ~..ns unm.rrl.d chlldr.n
b.tw..n the .g.s 0' Ie .nd 24 y..rl of .g. Who .r.
ful'-tl,. Itud.nts .nd who .r. d.p.nd.nt on the
Ellglbl. Memb.r for It I..lt 50S of th.lr lupport
and malntln.nc..
...nl I ..mber of the cr.dlt unIon who ts ov.r II
and under 69 ,..rl of Ig..
...nl .Iso Ih" her or h.rl.
...na . Ilwfully run Inltltutlon for the clr. Ind
tr..~nt of alc~ or InJur.d p.rlons und.r th.
dlr.ctlon of . It.f' of Phyllcllns. It must h.v.
orglnll.d facilitIes for IIIdlClI dll,nOIII,
tr'l~nt end lurg.ry. It .Ult hlv, 4.hour
nursing I.rvlcea. It dO'1 not ...n In InstItutIon
,rl..rll, org.nl,.d to tr..t the 1ged, drug Iddlcta
or .1coholtcl. It dO'1 not "In I nurllng hOlt,
conval.lc.nt home or . sl.IIar InstItution,
...na I ,.rlon .dmltt.d to a hOlpltll .1 . r.sld.nt
bed p.tl.nt Ind for whol' confln.ment the hosplt.I
chlrg.s Ita r.gullr .nd customary d.ll, ch.rg. for
rOOll Ind board.
.,.na bodily Injury clul.d by .n Iccld.nt occurrln,
whl,. thll PolIcy II In fore. .1 to the Inlur.d
'.rlon .nd r'lultlng dlr.ctly .nd Ind.p.nd.ntly of
.,1 oth.r e,us'l In lOll cov.r.d by this Policy.
...na .n [Ilglbl. D.p.nd.ntl
1. for WhOM the Insur.d Htnbtr h.s compl.t.d .n
.nroll..nt form .nd h.a agr..d to Ply the
pr'IlIUIII charg," .nd .
r. who h.1 b..n .cc'Pt,d by UI for cov.r.g. und.r
this PollcYI .nd '
J. who haa not b..n t.nnln.t.d from cov.r.g. und.r
this '01tcy In .ccord.nc. with the T.rmlnatlon
'rovh tonll .nd
.. who tl not oth.rwls, Insur.d .1 en [Ilglbl.
"",,"r or II en t1l91l>1. D.tptndent und.r tilts
'ollCy.
UIGIBLE
DEPENDENT
lllOIBLE MOIIIER
.
liE, 111M, OR HIS
1I0SPITAl
IM.PAmMY
INJURY
INSURED
O(P[HOIMY
.
. , .
I "~Ult[D tuJtllA
I "S\lAID
I'(RSON
lOSS
.
MOIICR
I'fRIOD 0' HOS'ITAL
COIl'INPPl
I'ArnlCll'ATlNI
A"OCIATION
I'IiINCII'AI, 11.14
YOU OR nc
tilt D IT U'U Oft
~! ut 01 TIt(
wf;lny
.
MI'"' .n (Italbl. Mt~.r ~~o h.11
I. ,~l.,.d.n .nrollftlllt forti .nd IV,..4 '0 "1
the p".IWI ,h.rO'II Ind
Z. bt,A ""PI.4 by ,,\ for' '0."'" "ndtr 'hI,
'oIlCYI ,"d
J, 110' b..n l,rMln.l.d f,OM ,ov,r... "ndtr thl,
I'ollcy III UClH4,IIU willi ,~ ",..lnUI'n
I',o.hlo"..
",11' both lh. 11I,,,r.4 Helb.r .n4 '''y 1"lu,.4
0.,.".11I.
"'111 I"Jurl whIch r.,,,It. III I." of 11ft or
bodtl, tllJurt of .n In,,,r.4 I'.rloll .n4 .cc"r, whll.
,"11 l'ollc1 ,. III fo,e.. lo., w't" ,.f","c. to
h,1I4 " h'"4', foot or f"l, "'II' ,'."'11(' It or
'NV' tilt wrtn or ,lIkl. JIlIIII. Lon ~WI
rtf,rt"c, t, '1' or 'Y" ..,II' '0,.1 ,n4
I",woe,bl. 10" of ,~, .ntlr, 'It"t Of the 'Y' "
.y.I, LIl" of .,..eh or h."III, "'"' '0'.1 ,n4
I,r,voc'bl' 10" .f ,,,,ch 0' h..,I... L.., wl'h
rtf",nc, 10 t~ .n4 In4t1 fl~' "'"' to,.I
I.u of tilt th\;llll ,n4 llIde. flll'" 011 ,lit ...
h,"4.
..'n' I /tUu,,1 'tr'on who II I....' of tilt
,,,4lt unIon.
".11. ..eh """" ~"'IO/t. Iucc.,.lv, ",104
of "OI,IUl cOlIff""""t 411. to tho .... 0' ,.I.t,4
C'''I', ,,"1.., """1'. by to NY'; wIll bt
(011,14".4 It on, p,,1.4 of ho"lt.l COli In"'lIt.
N.... . C.'"'' ""Ion tilt, III' .t'''. wlI" lilt
'01IcyIlo14., 10 ,.,tlel,.I. I" tht c.v','"
"ovl"'. bl I'" Grou, 1'.11'1' " ..'...."1 wlL"
tilt I'Oll(lhol"." ."ell cr..1t VIII", ..., ,.'f.... .'"
., ,II 4uLI.. of In. I'.Ilclhol..,.
NIIII tilt tIllI"", of IlllllrlM. """. ., tilt
111I""" .....1' ." 1111 (nrott_II' ,.....
...'" t~. ,.'lcl~ttl., c,.41, Vltl,".
lilt.". ,lit CUM filuLII.' '"'11""" Iftl.V ,r
",.I,~, WI..lftll".
GENERAL PROVISIONS
AllMIN ISTRATlVI CXPUISl or Tilt POLltYIIOI.OU. 1/, NY .,r.. to
r.IMOv'" yov fo, y~' .dNlnlltr.tlv. .xp.n'. In conn.ctlon with your
p.r'onaenc. 0' th. p,.,crlb.d dutl'l I' th. Pollcyhold.r.
AHlNOHfNTS. lhl, contr.ct ~'1 b. ch.ng.d .t ,ny tt.. without th.
eonl.nt 0' Ih. perlon, who ,r. th.n In,ur.d. A Ch,ng. e.nnot t.k, 'W'1 'ny
rlghtl of the In'urad p.rlonl which .ro" prior to the tl.. the ch,n" W'I
..d.. NO Ch.n,. wIll b. v,Ild unl"1 ,Ign'd by the pr.,ld.nt, . vlc.
pr"ld.nl, th, ,.cr,t.ry, .n l'IIIt.nt ,.er.t.ry, or the .ctu.ry 0' th.
$ocl.t1. An 'g.nt 0' the Socl.ty c,nnOl ch.n" thll eontr.ct, w,lv. .ny 0'
It I t.nlI or Nk. proml"1 Ih,t will b. binding on the locl.ty.
ClfRICAL IRRo.S. Cl.rle,I .rrorl In the k..plng or r.portlng 0'
r.cordl will not Inv,lld,l. Inlur.nea oth.rwl.. v,Ildly In fore. nor
contlnu. Inlur."C. olh.rwll. v"ldly t.rmln.t'd. Upon dllcov.ry 0' ,uch
.rror, an ,dJuI~nt 0' pr,~lu.', If .ny, will b. -.d.,
fH( CONTRACT. lhll Polley. with Iha APpllc,tlon ,nd ,ny .tt,ch.d
Rid., or tn4orl...nl, II Ih. .ntlr. Inlur.ne. contr'ct.
(RfOIT UNION R(CORDS You Ih.II Nk. Iv.ll.bl. to Ul. on r,qu..t,
.ny 0' 1~' ~okl .nd ,.cordl p,'I.Inlng to cov,r.,. und.r thll Pullcy.
DATA RfQUIRto. You wIll 'wrnllh In w,ttln, on 'OMlI I.III'.ctory
to Vi luch In'o,..tlo" '1 Nl ~ r.qulr.d 'or the adllnlllratton 0' thll
In.ur.ne.. lhtl wtll IA<lvd. d.ta on Inlur.d '.rlonl who .r. b.comlng
In'ur.d, whOI' Inlvr.ne. I. t.Mlln.tln,. or who Ir. ch.ngln, '0 . dl".r.nt
plan,
effeCTIVl DATI or COVERACf. lh, Inlur.nc. on .ny IIlglbl. Klmb.r
.nd hll 111,lbl. D,p,nd,ntl; I' .ny, will t.k, .ff,ct on th. rr..lu- due
d,t' 'ollowtng r.e,lpt 0' h I ,I,n.d Inro".."t 'OMl by th, cr.dlt union.
~ CHANGI, An Inlur,d M.Rb.r NY ch.n,. Planl whll. thll polIcy
II In fore" by ,.-,I,tln, , n.w fnroll..nt 'OMl ,nd lubll'tln, It '0 th,
er.dlt union. Inluranc. on th. n.w PI.n will tlk. ,ff.ct on 'h. n..t
,r.-Iv. due d.t..
IVIOfNCI or INIURAlILllY. 1/. Ny r,qulr, from In 111,lbl, ",~.r
,nd .ny of hll tll,lbl. Dep.nd,ntl. ,vld.ne, 0' Inlur.blllty .1 p.rl 0' th,
tAroll.."l p,oe,'ur'.
GAACI PfRIOO. Thlt '011', h., . '1 d.y ,r.e. p.,lod. lh'I ~..n.
'hll It . ,,",11/1II It 1I(t\ p.ld on or bI'ort lh. d.t, It II du,; It NY b.
,.Id dv,ln, lhe ,.Ilowln, 'I d'1" Durin, th. tr.e. p.rlod th. ,Iley wIll
tt.y In ore" The 9"" ~rlod will no ,pply I' &hl' 'olley 'I
t.,.I".t,4 .1 t~ SQ(I'&1 Q' ~1 l~ ",dl' union.
'~C$TAlILI'Y 'hit roll'1 t~." not b' ,ont"t,4 "l,' % y.,"
'r~ ,_, ("tetlv, 0." .."" 'or 4On.,.~nl 0' ,r..l~t. No tt",..nl
"..4. h ,n lntv',. ""fit Nt ~. 11..4 '0. wold '.111"11(' " to d'.I' ,hi.
~Itt' t~. tt.t~' It tl,-.; ~I ~I.. Att" % 1"" ',oa ,~, "t",tv.
.
;
Dat. of Insur.nc. on Iny Insur.d p.rsonl no st.t,~nt ..d. by hiM Cln b.
used to void thll Inlur.nc. or d.ny I C 11M.
INDIVIDUAL CfRTlfICATf5. W. will I,su. to you, for d.llv.ry to
tlch In,ur.d Member. I C.rtlflclte d'lcrlbln, the Inlurlnc. cov.rl". how
b.n.fltl will b. plld, Ind the rlghtl ,nd prlvll.g., und.r the t.Mlt of
thl, Policy.
MI5STATtM(HT Of AGE. If the .g. of .ny In,ur.d N,Mber hit b..n
mll'tlt,d, III .tountt ply.bl. und.r thll 'olley will b. lueh at the
rreml~ p.ld would hive purehtl.d .t hll eorr.et .,e.
R[IN5TATEMtH'. If Iny eertl'lc.t. which I, l'lu,d und.r thlt
Policy t.rmlnlt.t b.e.uI. of non-p.yment 0' pr..luM when It It du., It ..y
b. r.lnlt.t.d within )0 d.yt frOM the d.t. of tuch t,nllnltlon by payMent
0' .11 ov.rdu. pr.mlums .nd .vld.nc. of Inlur.blllty I.tlsf,ctory to UtI tf
w. r.qulr. It.
RENEWAL Of POLICY. Thll 'oltey la t,au.d for . t.rm 0' on. y.lr
but mlY b. r.n.w.d with the eon.e"t of the 50cl.ty ..ch y..r th.r.l,ter.
STATtHf"TS 0' INSURABiliTY. All tt.tement, ..d. by .ny p.r.on
r.l.tln, to hit Inlur.blllty Ihlll be eonltd.red to h.ve b..n mid' to the
b.lt 0 hll knowledge Ind bllt.f. No It.tement .,y b. uled to cont.lt
Insur,nc, un"11 It II In wrltln, ,nd algned by the p.raon making the
,t.t.ment .nd unl.lt . copy h.. be.n glv.n to him.
PARTICIPATING . DIYIDtNOS. At the .nd 0' the a.cond y..r. Ind It
the .nd Of e.eh aubtequ.nt poliCy y..r. thla policy, whl,. In forc.. thlll
plrtlclp.t. In the dlvlllbl. lurplul, I' .ny. .. Ipportlon'd by the 'Olrd
0' Dlr.ctorl.
,
.
* . .
I(MltIll
Whll. thh rClIlO It '" 'orn, IlIt"r.' ""(IIl' tr. Clnr~,., U ,,,,,,. I U1.
36$ d,,1 . Y'" ""11" 'CC'.'"" III th, ,tv',. I' ~"ftlll Ir ,I...ur..
Cov.,.,. Inch"'" ("", It 1I0t IIIH.. tll) .ce'.,,,,, .'''-r 011 or oft tilt
Job. ()(Cllrrlllt 'n th, h., Inv.lIlI, It . '''''lit'' ., tr.III. ,'r,I",.,
automobtl. or other ,lIbllc or "tvU. tr,".,.rtu I.... tilt ","," It
provld.d IIl1d., thll 'ollcl .r. p"a~l. III ...1"011 ,. '"1 olhtr '"I""nc.
whIch .al b. in ,"oc, It tht tiN ., lCe'd'"'.
It .n In.ur.d '.rlon lu.,.lnl . '.11 wllhlll ,.. d.,. afl., th' d.t. 0' '"
.celd.nt. w. will P'1 In on. I~, lit, Indlc.I.. ,.reOlll.g, of tho 'rlncl,.1
Sum .I.cl.d '0"
Lon 0'
lH.
Doth H.ndt or both ,..t
Slvht 0' lolh ".t
On. h.nd Ind Oil' 'oot
On. h.nd .nd II,ht 0' 011' '"
On. '001 .nd Iltht 0' OAf '"
On. h.nd or on. 'oot or
Ilthl 0' on. ')'1
Sp..ch 0' h."ln,
Thumb and Ind.. '"t.r 0'
..lit hand
Mt,t
1001
1001
100S
1001
1001
1001
101
tol
III
......J!!Uzlle -- .
~~
tOI '01
101 rOl
tOI rOI
tOI rOl
tol rOl
tOI ros
It, 101
UI 101
UI II
Only on. b.na'I', the I.,..., ,. wh'eh the 1111",.4 '.r..n', .nC'tl.4 t..
It pay.bl. for. I 10"" r'I"ICI1I9 fr.. OAf .ee.4.1I',
DfPfHDfHT (HILORIN ItHI'IT. If '" 11I1"r.. Militr ,I"CI 'hi ,..tly
Phn and loUt hit lIf, III 1/1 ICC'..lIt, w. wll1 '" 11.000 C. Illt
~,n"'clarl, for ..ch ch.ld who I' '" '",,,r.4 Ot,.lI4Il1t Oft .hI 4... ., ,ht
mld.nt.; Thh ..ntf" I, 1/1 U4U'," t. .11 .\ht, M",flU P.,._,. 'I'
lOll of 11"0' .11 In,ur.. Htabtr vn4t' '~II "',c,.
. .
GOlOEH AGE '1I0nCUON. If ,n IIIUrt' lit., .' "" IIl.vr.. '""It
.Hil"rn. '7O"'whlh '",,,rod, com.,_ Nl CO"&lIl'" It 10flf II tit, ,r.'lIIl
,. Plld, and ~Qlh tll. ..tlc ~"Ilt .114 .~ "lnel,.1 ~ wIl". ro,,,(04 "
followtI .
'u..'.#'. ,
.....,
I. .;IponatU'Mtnt of av. 10, 'II. '1IiOU'" .f III'tir.ne. It "tlllu' -, 1011
and. .'
1. upon .IUI/WlIl .f .t. 11 .114 tilt,..,.." 'hi ~nt Of fllltirfllCO
r.~11l11l9 I, furth., ,.duc.d ., "S.
/lO~PllAL (,4JH IPun. It IIJ)II'1 (III'" '" IIUli". 'mM .. "
(oflflllfd III' ~"H.. II '" 1".,.1I'1I' .,,"11t .". '''' fif .", 4.', ot 1M
.((ld,"I, w, wIll ,.y . ....'It 01 'S of ,-. 1.'uJf4 ,.,.~', "l~l", t ~
for tiCh MI Nil'" of C.4tl...... IIf to . ....IM "litH' ,f tI,...,
.
i
lI\(lnlll. Th, (ontln'llflll ifill" b, for. l'trlOd of IIOr. I".n 1 city.. '".,flU
will b. ,.I(ul.l.d frQM Ih. flr.\ 4.y of (onfln...n\ .n4 wIll (on'IIIW' for
II IOIlV ., lilt In,wr,d ',rlon I, '0 (onfln,d, bUI for not .or, 'h.n "
'~nlll, In '111 on. p,rlod of confln'IlfIl'. for. p.rtl.1 IIOnth, ..ch d.ily
I>'n.flt will lI. f/t1l.1 '0 I/JOlh of UI, Klnlhb \!>tll.flt.
IInlAUOll lUAlIO. ("h Inlwre4 ",IIII;,r WM h.. ,I'H,4 11\ .ddltl(lIl.1
'11I0111\' of Inlur,"u ('rIll( Ip.1 l\lll), 11111 tI. nv.r.4 uAlltr tll. IlIfl"lf'"
Qu.rd b'fttfl'. fv"y two ""'r Oil ,,,. '11111""", 4.,. of ,lit '",u,.d
",_1;.,'. 'IIroll,,"\, hIt orl,ln. 'MOWn'.f .04.4 (ov.,.,. wIll tf
.1I'o-I\lc.ll, In<r...,d II. 'hI, b,lI.fl\ 11111 cflltlllu, t, Iller,... ,Ilt
'nlllr,d ~r'. (ov,r.,. .t lon, .1 II. r...lnl III.u,.4 11114., the p,.,r._,
(If unUl hit eovor.,. II.. ...." hIH.."d . fllll rn, Any ch'1I9' In
'rlncl,.1 SijI or pl,1I "P' wIll b.,I". "'W ,.rl04, .t r.I.,.4 ,. hIt
b.n.flt pr.vltlon.
.'""'C'AaY, Unl.'t '", Inlllr.d Mtmb.r "lIt ut o,,,,rwll', hll
I>,n.flcl.rl IInd.r \hl. 'ollcl for I"Iyr.nt. ,.y.bl. for 10lt of Ilf"
,
I. on ,II. d..," of 'h. Inlllr'd ~\.l.r wIll lI. III, .,oUI', I' 11.1"1,
oth.rwlt. hit "''''I
1. on 'h. 4,'lh .f tll. IIIIur.4 ~,r't .pou.. wIll D' 'At '.'u"d ~'"
If 11.1119, 'l"'rwl" ,,,. "l.t, of '", 'pOut'l
J. on lilt 4..,,, " tilt lnlV"d ehll;r,n wIll.. ,h, '".u,.4 MtIO., If
Ihl"t, .,lItrwlt. hit .ptWtt, I' Ihlllf, .l".rwlt. Ut, .UU' .i 'h.
Intuft. ehIl4"",
CHANGe 0' .tNr'lcl~'. 'h. 1".ur.4 MIlO., h.t ,lit ,t,,,,, whlll
Ihlt '011el tl In '"el. ,. Ch'"" hIt "ftt'lcl", w'l"out c'''''''l It th,
~.ft,'lcl.", 'I wrtt"" ,.qu.t' '" tllt f,r. "I' I"tt '~'pOl' .~,pll'4 b,
lit. lllt ch'''9' wIll ,.k. ,'f.e, .~'" .1140,..4 '" hIt t~lylfll"
(,'llflc.l. ., .~, ~ Of'I(.. U"" 'v(h ."40r...."', lllt ch'''t. will
r.l.t, '.ci ,. '''4 ,.k. "'.e, .1 " Ill, d'" lit .1,,,,. the "4vet' wh.t""
or f1,1 h. It Ihlll' U I'" "Ill w, ft"h. ,'" "1f1l.1\. An, "4~.n 'Of'
(h.",. 11 b.",'lel." will "01 .'f,el '''t "l."t ~4. 1~' "f.'. WI
""lv.4 hI. ,.qu..'. ,
(lCUQ 1011I'
W. wIll "'1 "1 . .,,,,fl' '0' '''1 I." I. .n 1"'11,.4 '.r.," "11,.4 _, If'
fuultI", f'MI
1. 'lIletH willI. ..lit .r III""" '1'
1. 111\'''''1".11, ..H.1Atllel.. IIIJII',. .r
}, _.cl.r'4 " 11114.,1".4 w., " '1\1 .et I~""', .r
.. ,I, ".v.l .. . 'II" " cr.w ~'" (p'
~, .""11",. MOl., '.11141. Willi. 1""414".4, .,
$, rI41",., 4,1,1", 11\ '''1 k'n4 .f ,.e. .1 . ~"""''"'', 'f'
/, (~I"I",.r .,\,~'I", I' .~I, . ,,1."1' "
s, ,ql~"\"1 III' Of '''I 4f~q, ..41.1~, '1' ,.4,t',t, ..C.,t .t "'1"...4
.1 . '~I'.cl'l\.
.
U1UUNATlOM Of INOIVIOOAl 1~l.lIWtCf
Intur.nc. on ,ny Inlur.d '.rlon will autOMatlc.lly t.nlln.t.,
, '
I. on the d.t. th.t you stop p.ylng pr..lu.I, al r.qu.st.d, on beh.'f of
the Inlurld "'-b.r or his Intur.d Dep.nd.ntl, or
Z. on the d.t. thlt .ny r.qulr.d pr..luM h.1 not be.n p.ld by or on b.half
of an Insur,d P.rson, or
). on Inlur.d Otp.ndtnts, th, preMIUM du, d.t. th.t th.y .r. no 'on,.r .n
Ellllbl. D.pend.nt, or
4. on th' d.t. thtl 'ollcy t'rMlnat.., or
.. on the d.t, the Inlur.d MIIO.r'. tnlur,ne, t'nlln.t.s for .ny ,...on,
Including his d..th, Inlur.ne. for ..eh of hll Inlur.d Dep.nd.n', wi'
.110 t'rMln.t. at the I... tl..,
,
.
.
. 7 .
I~ 10 fll[ A CtAlM
You mUlt wrH' UI about e chlm within %0 dlYI Ift.r the occurr.nce of In1
10.1 or al lOon al you can. W. will provld. you with claim forml'.or WI
will I,nd th.m to you within I' dIy' .ft.r you t.11 UI .bout the Claim. If
w. don't I,nd the form' In II d,yI, you Cln limply I.nd ul wrltt.n proof of
the IoU. lh. proof lIIUlt thow the dlt., the chlrnttr and ..t.nt of thl
Iou.
You mUlt I.nd proof to UI within 90 dIY' .ft.r th. dlt. of such 10'1. If
you cannot I.nd proof to UI within 90 dlyl, you MUlt do '0 a, ,oon ., you
can. Unl'll th. Inlurld '.rlon ha, b..n I.gllly Incapabl. of filing thl
Ilroo( of Iou, w. won't lenpt H If It It flI.d aft.r on. ~..r frOM th.
time It Ihould have b..n fll.d. You or th. lnlur.d '.rlon can t ,tart a~
l.gII action ag.lnlt ul until 60 dlyl aft.r yOU ,.nd us proof of lOll .nd
you can't Itlrt Iny 1.gll Ictlon Ig.lnlt u, MOr. than 3 y.arl .ft.r you
hlv, I.nt th. proof.
PAYMENT 0' C~IMS, Th. b.n.flt for 101' of 11ft will b. payabl. In
.(cordlnc. with th. b.n.flcllry d.llgn.tlon Ind th. provlllonl r.lp.ctlng
Iuch pI)'llllnt which .Iy b. In ,fftct It the \IN of p'yNnt. All oth.r
b.n.fltl will b. Plyabl. to the In,ur.d M.mb.r.
PItYSItAt. UAI4IMATlOHS AHO AUTOPsy, W., It our own ..p.nll. h.v.
th. right to ..amln. .n Inlur.d '.rlon a, oft.n al II r.llonlblY r.qulr.d
whll. . clal. II p.ndlng and to mi.' an lutoPIY In ell I of d.ath whir. It
II not forbldd.n by law.
PRD4IUM aWlGES AHD ,AYMOO
Pr'lIIIUMI for thl' 'ollcy will b. paid to UI In edv.nc. on . quarterlt
b.III. Th. NthOd of premlulI Plymtntl may b. ch.ng.d to ,..lannual1t or
.nnu.lly by a,r.tmtnt b.tw..n th, '01Icyhold.r end Th. Socl.ty. 'r..tU8t
will b. c,lcullt.d on the bllll It.t.d In the Sch.dul. of 'r..IUIII ,hovn In
your ApplIcation.
W. have th. rl,ht on any premlulI due d.t.. bl ,Ivlng adv.ne. wrltt.n notlc.
to you, to ch.ng. th. pre,IUM rat.1 .ppllclbl. to Insuranc. provld.d und.r
thll 'ollcy. A chang. In pr'lIlum rat., will not b, mad. mort oft.n th.n
one. during .ny policy y..r.
TlAMINAtlON 0' tHIS POLICY
Thl. '011cy will .ut~tlca'ly t.rmlnat. if any p,..luM II not paId wIthIn
th' Grac. '.rlo4.
thll '011cl ..y b, t.rmln,t.d .t any \1.- b1 .Ith.r the Socl.ty or by the
cr.dlt union wIthout pr.Judlc, to ,ny ..I,tln, cl'I.'. Wrltt.n notlc. 0'
Int.ntlonl to t,rmln.t. thll 'olley .u.t b. ,Iv.n, on, p,rty to the other.
.t l'l.t )1 4'y. In .dv'","
I' thl, 'olley t,rmln,t'I, yOU ,htl1 b. 1I'b" to u, 'or the pl1"nt 0' aI'
prt.I~, which h,ve not b.,n 1",lu4fd In '"1 pr..l~ "1I'"t.
.
. 1\ '
_ JVfUAJ. INSUlWlCI lomn
""hOll. IIIICOIlI'n
,.... ClU'.MI'1
lllOC)AUMlNT 0' tonMGt
In conl.d.rl,'on 0' th. p".Iu-. thll (ndor....nt I. ,tt.ch.d to ,nd ..61 I
put 0' GrOllp Accld,nt.I De.th .nd OhllMli'I'Nnt 'oHcy No, '
- '
Th. Sch.dvl. 0' ',n"'tl In th, 'Ollcy I. ...n"4 to 'ncludt th, 'ollOWln,.
(.ch fllllbl, "~r who h'l ,n,oll,d 'or 'nlur.ne, .n4 ,. inlur.' un4tr
th, t'nR' 0' 'hI, PolIcy wIll b' Inlur,d 'or thl ",000 "I'C Altvnt 0'
Inlurene. on . nOft-contrlbvtory b.II.. Thlt wI I b. 'n addItIon to the
.ddltlon,1 'MOunt 0' In,v,.nc. ("inclpal tv.) ,I.ct,d by the Inlvr.d
Metllb.,.
IN "ITNtsS IIHlAIOf. tUNA MUtva' In.vrlne. Iocl.ty h.1 C'UI.' thl.
fndor....nt to b. ..ICY'" by itl ~Il luthOr',.' ."Ic.rl th" ~
d'l 0' . .t . Thll date 'I thl e".ctlv. D.t. VI ,nt'
'ndor....ii\, --
(UNA ...nJA&. IMSUMNCI soclm
"ltl4'lIt
,
AtmU
1""tl'1
&'P!JlmroW~ID
_111M
G~vUP A & H
'fl~, ,,me,! "OC,",AIlTI/~HI
'1~U 0' tt,{lAC(>>.~
.,
I'i 1,\ ol~nth U
CUM MUWAL IIUUUIICC IOC my
f" ~i'ij)m m ~11 r~:!!J
JUL 18 198&
Gl1vuP A & II
1.....UHANce Ol!PARlMI:tH
"'ATE OF WISCONSIN
~4'.Oft. Vllcon,'n
ro-on.. Ct1ttorn'l
INOOIlUMflfT or COYlRAll
In con,tder.tton of th. pr.Mlum, thll Indor,...nC II ,tt.ch.d Co Ind .,de I
p.rt of QrOllp ~cld.nt.' IltUII .nd DhlllMbt,...nt 'oHcy No. .. .
lhl Sch,dule 0' ',n'flCI In the 'ollCI II 'mlnde4 to In,IlId. thl followln'l
I.eh llf,101. ~r who h., ,nrol1.d for Inlurln~. .nd II Inlur.d und.r
the terMI of thll 'ollcy wIll.. Inlllred for thl , "Ifc ~lInt of
Inlur.ne. on . non,contrlbutory ..111. lhll "ltc-AMOUnl will be In ,'f,et
for I ,.,104 of Ollt y..r t,OII thl lfftcUn Dft. Of tilt 'nlured Hlllber'l
~OY"'" Ind wll1D' In. 144ltIO" to ~. Iddltlonll ~"t of fnlurlnee
('rlne ,.1 tu.) el.cted oy tilt '"111,.4 ~r,
IIf Vll.ISI WNlllO#. (UNA Mutllll 'nlur.ne. loellt1 h.1 e.uI.d thl.
Indor....nt t. .. .atevt,d bl ftl ~11 luthorl... o"lc.r, thlt
d.y 0' iiftl . I'.... lhfl 4.t. tl '''' I"ecttv. Olte ~
IlIdo'....n .
CUM MUnw. INS~C lOC,m
,
"..I.ne
AU.."
ktl't"'1
,
.
tIt. JOt.OtU.,
I"
Qr~TIrICATIQN
I, B.th A. Andlnon, A181atant Viol Pre.id.nt or credit Union
In.ur.ne. oivi.lon tor C.ntury co.panle. ot A..rica, an attiliat.
ot CIIMA MutUal Ineuranc. .ooi.ty, do h.reby e.rtUy and atta.t that
the athah.d h.r.to ie a true and oorrect Ip.elll.n copy or the
Oroup Aocidental D.ath and Ole.emb.rm.nt C.rtitioat. il.uld to
O.orQ. D. 'e.uta on ,.bruary 1, 1917, Und.r pelley
No, Kla.J01.0113/~.v..6 by CUNA Mutual Ineurane. Sooi.ty,
~~ f?f? rlt1.;'~
Be A. An .rlon
stat. ot IOw~ )
County ot ,G.lu....f'nl-J ~ II
sUb.oribed and orn betor. .. on thi.
,JItoo/A't d Y ot , 19'L.
Notary
)
.~~,J county, Iowa
f!~"/9 i
,
My co..ll.ion .xpir'l
ft,
CUNA MUTUAL INSURANC"F f\nrn:TV 'NC.
t. u bOil to, WrhI!I'" 'OW<I ~.{lfi!1
It ..llptll'Vl II') t.1 oulq
Cl,mrtCATI 0' IHIiURAHCC
0'0\,1' A..I4fn.al 0..'" tIlII OI_/II"f....n.
(1',-,.. "',, 10 INtI! PoIJoy HU/llbtt 1M Ctt\UIHIt
Numtltl In anV wmmijftlOlllon H/IMflIInO W'
Intlll"," I
I""
INIVRriD MeMPCA
"'"1
,
!:U~~A:~~ApA 17070
l
,j
flOLICVHOLOIR,
HAMI 0'
PARTlCI'A lINa
.IIOCIATION
HfH"U COV'MIII ."QJ' INIUMNeI nun
Jf~Mi.~~::=J =:.-l~'''';~~1
'CHlIM.'
Cl'firlFlCAli NUMDtA~I-= affecTIVe DATI
0066.'" "l'Ot A,&~~l T"'" 111M
___, '" m_ "__!'!aI1if"'I(!II,.~'lIel1' tit , "
PRINCIPAL tuM
'*'IMIUM
. ~.'O OUAA,.ALY
.........._>~_~r.
~ 0# IHtuMHCI
11..10 Amoun' (NorI'OOfIIrlIMOfy):
Mllllonal AtflOll/\l (C{II\tflWlOIyl;
" All ,..tU.f.i<<t1;;;;~ ~. ,......, ~ II 10 ....
1....11... 1~1>t1~7}!~,!~~1.N!lL
11,000'
... Amo\IftI (MM." Only) .
AMiO/III A/IlO\IIII'I"'OIVIDUAL covauI.
"NlflCWty - ., I' Off ,"
.W:'~.._.,,,~~=,..,,4,:t'''''C,,,,,,-,,~,,,,,~~,':t'.:.,~.,.-:C"1=~''''.'''~",.~.-':"~-:'_,.._,..__..;<~.~-C7>
w. ~.rtltJ 1t1., I"M, W, II' NMI tile PfMIhMN 1I.w 1M ~ f'oIIf, .. \IIt1....mt M. 1M ~ Mf/1INf ~
"rIm" If "yWl" I/fII1tIIM c.ro/lMlf'", InfIlHM4I1H ....,. ~ 10 "'" "'1M ., 1M ~ ,.-,
OnIHIHOH" A. ~/lllfl1II1M CtttI",", """'..,-~. '^' ~ ~
I~ ..."..., Ifilf/W . ~ III IN ,~.., "'lM/Im 1flwI It".,,,, I' W IIfI4M 10 YtM. iii ....
f~~"" o.~ ~ 'fF;iN ~ ~ litlfPllfN 10 ywt" .., ~ 'ffiiIf Wlf*MfW. ;1' IJ1'HJ1It "ffl fHI4M
'. ,!till. fA.",. If ~ ~ ~ ~~..""'... '. tf'!I U ,Mr. III till ~ Wf WMIf fiflI(,f 1-' tfI4
...". "''* 1140"""....... iofi tIN fw ....... ~ .,...., ~ W ffiAIRttf'VU .
'''Ii, (.I..... _....If IN! ~ li!A ~ IN! ~iiI'H 'fl1"i ....
,. I,l '1<,/ ,,,,In "'fl.. "
~.lt". .....~..
.. '.", .-- ...,...,-....-....
10'II/loe. ,.rled mtlnllllllhr.. mAAlh I'"'rlOO btogloololl M ,,,II 01 Ih. folly 01'" "I.".d by Ih. ParllclpaunU
^""lI.hvn
110'1'1111 maal., I l.wlully rllo 1/l.1~\II1(l/I IOf II\lI ~r. Ind 1It1lm,nllllllck Of lIIjurtd ".rlO/l' und.r 111I dlltlC;lIon 01
a ,lalll.I I'hy.ltllloa II mll.1 "IY' orlllnl'lld I!WIIlI.., fOI "",,!Cal dllllnotll.II'lIIlm,nl and IU/IIIlY.1I mUll lilY' ij!4hou,
nurtln(l "'\II(:" h dOtl IlUI mtan an InaUluIlClII primlfdy org",I,,,, 10 \f..111It IV.d. drug addle" 0/ .tcahalltl II
(l(.1Ot ril'l mlUll1 . IWralf1\ll\(;mt, ~".~nI horn. Of I .imU"lotlll\lllOl1.
101',11'111 mtlnl 1II I'""1OIl a4/IIIll.d \(J . hotpllal II I I..ldtnl bid P.1I.1I1 ",d lor who.. conlln.m,ollh' hotpllal
t/..,(jtI, ,It 'fllIUI" ,nd HI.'OIIIary dlllt, "II,rgll 101 mom Ind bOard
hltvlIlI '"lOn mun. both YOlland VO\If IlIavlell O.ptndtnll. if any
Injury !".'n'bQlldY'!'!'t!l~!\JH4t1t.JQ _""Dl *",mng will" ,'ilt, OIOUP Polley I. In tOle. 1110 Ih. lnlll"d r,r.on
'ifill '.'ultlllg d""lly IfuI ftidtpt.1l1Iy 01 11II Cill1tr elll'" in 10" OOVlft4 bV lilt O/ouP PollCV.
~ ga. 1JI'"t..,-ln!\t'l.wtl~h!tt.1ol''' I!l....~ Itl, Of bol'Idy InII.tfY III an In.lIttd ""100 and oceUII willi. lilt a/OUp PollcV
I. in II"'. ((IN wilh r,'e,(I/\ClI1O harlll Of IIIr1l1., foQI 01 ,..., lIIIan. Nylfl/lef II or abOv. III' willi 01 ankle joint
(fl" D4ulh C.,olln. r,tkMlllI. lot. CIf 11IM Of hW' "10 m.lo,lOt. 01 Iollt Ilo{ltrlll.OH with r","n~' 10 'V' or
ty'" ",'lII\t IQI" ,lid ll11VOOIfllt lot. Of lilt .olllt tighl CIf lilt .y, Of .y". 1.011 01 tpHCh 0/ h.l/lng m''''" 10lal
,,,a U"YQ(:abl.IOllI 01 IPfflih 01 lIt"l/Ig 1.01' willi """not \(J Il'IlImband Indf. "1IQ1f m..nlIolallot. 01 1h41lhumb
."', UIII.4 IIfll1t1l Mill. h!fie hI/ICI.
,,,104 of "'"pl'" ClJftflMfMllC maIO' NOh """'1" OlIt'llOn, .~ ptrlOdl of hoIpIlaI OOIIII/Itllllol clue 10
It.. ",f1, (>1 r."I.d 1i1llN. IIf\lttt "f/llI~ by to dlVI, will tit fIll/IlldIftd II O/It period 01 hotpltal (;(l1l'llIImenl.
"lMt,., llIIft 1II,IIf\I tilt AcidIIlURaI ~I CIf IntUf,"" w~ )'OV .ltCi1fd In yOlll ell/oI\m.nl p'o/m.
JINI"", w"'~. \/lit QI~"~..1n .ftM. I/ItvItcf ,.,100.'" OOVtttd 14 hour.. d.y. HI d'YI' V.lIl1OtJntl
."'.id'f1't In u.. MiUlN Of wtiAt.." pMUVI.. CoYtt'" ln4\lIdI. (1M It not limI1Id 101 ~'o.. whtllll/ on 01 all
th' II'\), Q(:(;\lIf"'lI1II 1M 1'tQmf, ""flInt It I ,..HnGIf ty 1I1l/I. altpllllt. ~ Of olhtr P\lbllO 01 prWI"
If ...tlllMItII(l/l n.. bttIt'"' IifWM ~ 11'1I 0t0\I0 I"0IItIV tI' !>IV_In tddmOIIlO any otIItt IoIlllI/Ief whkill mlV
... III ,,""1 1\ 1M \lIIIt Of II\lI M~'"1
If an IlIlwrlld 1'.,tOIltlltlfll'll.lt.. w!ltIin MI IIIVI tlttt lilt d... Of III ~. W. WIll P.V In OIl. .urn. IlIIlndll;.It(l
ptI'W'I~ (111M 'rlMlfilt turn IIIUf.d 101:
1.011 0'
I.tI,
II!IIh Hanft " __ ,...
IW;hf if ~ '1ft
Pt.. ..."" , ~ ,...
r;".. HIfld A!. ., (lilt '. "
0,.. '00f. . ., 1iNI'14
Of", ~tM"4 (jI ,. fH
~ III 0.... I,.
~fjf~
f~. ~4 't(lfIJI"
....".. .~
IAIIC
AMOUNT-
IMWH ..."'",
l~
l~
,~
,~
l~
I~
I~
I~
I~
ADDITIONA" AMOUNT
'lIIIlIW ....n
fMWM ",mil" lnl\lfM ',.uN Dt,.II4'"lt
...11 CIlIkf
tOll'f
IO'It
~
~
~
~
, (lC)4t
I~
, IlO"lt
lOO'lt
I~
I"
~
to4i
~
~
~
~
w..
~
,...
~
~
I~
I~
I~
t~
(~f ~ ......t H ..~ I!; .~..... .,1li!S1..,....... !II "". r.11(1, .. ...... .. till .... I~ 11_ "'..
"'";...._.<1i....'
. t".. "'...."....' '#of...."'.. il'", !li"'~ ......."" i*~""" ~ w.. ....~... ~f (0, H ,....'W>....""" A.,...,..,,,,,, ~~I
~ 1"- 4'tiil~.i,,~ t,) \:ftJ "'.-"f';.,':--t",'l ~'_~'.io~,
EXCLUSIONS. We will nol pay a bone'" for any lOll 10 an tnlured Porton cauald by or ,eaulting Irom:
1. ouiclde whllo Bano or Insanu, or
.. inlontlonally lell,lnlliellld injury, or
3, lledar.d or undeclared war or any act Ihereof, or
4, ai' \lavel BI a pilOI or crew membll, or
!l. oper aling a rnolor vehlcl. whilt InIOlieal,d, or
l), riding or driving In any kina of race al . prOf,..lon.I, or
7, commuting or aUlmptlng 10 commit. Illony. or
o volurllary ual of Iny drug, m.dlcln., or ..dlllv., 'Icepl .1 pr..crilMld by . phYllci.n.
DEPENDENT CHILDREN BENllfIT. If you IIlv' at'tt.d Ih. F.mlly pt.n .nd 10.. your Ill. In .n Iccld.nt. 1'1'1'1111 PlY
.1,000 10 your ban,lIeiary, for "ch child who il In In,urld D.p.nd.nl on th. d,l. olth. Iccld.n,. Thll b.n.IIlII
In addition to all other b.n.llla p.y,bl. lor Ion 01 IiIa 01 ,n 'nlured M.mbtr under thlt QIOUP Poltcy,
GOLDEN AGIl PROTECTION. If you or your Inlured SPOUIt aUaln .gt 70, cover.g. mlY conllnu. .. long II Ih.
l>furnlurn il p.id, and bolh lilt Oallo Amounl and th. Prlnclp.1 Sum will bt ttduc.d .. 101101'11:
" upon altalnmenl 01 Ig. 70, Ih. .mount 0' Inlur,nc. II reduc.d by &0%; .nd
... upon alt.lnmenl of .g' 7& .nd thll..IIII, Ih. Imounl otlnlur.nc. "m.lnlng II lunhll reduced by 7&%.
1l0SPlTAL CASH BIlNEfIT, II Injury c.u..l.n Inlur'd PI"on 10 b. conllned In I holpllalla.n In.p.tl.nt wllhln
on, yaar 01 Ih, dal. of th. 1"ld.nl. W. will PlY . btn.III 01 1% 01 Ih.lnlur.d Perton'l Prlnclp.18um lor 'ICh lull
monlh 01 conllnlm.nl, up 10 I m.limum btn.1II 01 ",000 ptr mOlllh. Thl conlln.m.nl mua' bt lor. ptrlod 01 more
Ihon 7 dlYO, O,nalllo will bt cllcul'lld Irom Ih. flrl' dlY 01 conllnlmlnl .nd will conllnu,lor ..long IIlhllnaulld
rerlon II .0 conllnld, bullor nol moll Ihln l:l molllhlln .ny on. ptrlod 01 conlln,mlnl, For I pI,,111 monlh. .Ich
do,ly bln,l'l 1'1111 b. ,quII to t/301h 01 the monlhly ban,llt
INfLA TION GUARO. If you ,I,,"d In Additional Amounl of Inlur.n'l (Pllnclpll Sum), you will bt covIr'd under Ih.
Inlll1l0n GUild ben.lit. Ev,ry 11'10 Yllra, on the .nniv,r..ry dltl of your Inlollm,nl, your orlgln.1 amounl 01 add'd
wVlr.g. will ba lulomllitllly IncreUld tfllt. Thll bln.1it 1'1111 continue 10 Inct.UI your ooverlQt latong.. you remlln
Inlur.d undlr Ihl plogram. 01 until youl coverage h.. bltn Increaatd , lullll&flIt, Any ch.ng. In PrincipII 8um or
plln IWI will bagln . n.w period, I' r,I",d 10 Ihil b'otllt provlllon.
DINUIT PAYMENT'. Th' b.n.liI lor Ion 01 hf. 1'1111 be plld In .ccord,nce wllh Ihf btn,'lclary d..lgn.lIon .nd Ihl
prov'I'onl regilding au,h p.ym.nl whl,h mil' be In ,",ctlllh.tim. 01 plyment. All olher bin. IlIa will be plld 10 you.
IUNEfICIARY. Unl... you t.1l UI OIhtrwlll, your 8totflclary under tilt Qroup POlicy lor Inluranoe payable lor Iou 01 Ill.:
I, em your d',lh wilt b. your .pou.., " living, ollltrwl.. your ..1.11;
2, on thl d..lh 01 your apoutt, 1'1111 b. you, If living, otlltrwl.. the ..t.l. 01 your apou..;
;), unlh, d.alh 01 your Inlurld thlldren 1'1111 .... you, It liVing. olh.rwi.. your lPOU". IIIMng, Olherwi.. the ..tall
"f you, Inourld chlldr.n.
CIlANoe 01' DINI'ICIAAY. You "'v, lilt right, whll.lhl Group POlicy II In Ioree..o Ch.ng. your D.nlllcilry wllhoul
wnl.nl ollh. ban"ici.ry, by wrlll.n requII' on IhI Iorm IlX thll PUIPO" IUPpll1d by Ua, The chl/lOf will Ilk, ,".et
whon IndQratd on your Indivldu.1 C.""Ie.I. II Our Horn. 011108, Upon IUC" .ndOr..ment, lilt change will IIlat. blek
\(> IInollk, .11,,,, II olth. dill you .lQnld th"equtll wlltlher or not YOll Ire lIvlnQ lllhe Ilml W, rtctlv'llIt requI."
Any rO'luo'IIOI ehlng' In ban"leiary will nol ."acl .ny p.ym'/ll made by Ua btlo" Wa rtcllved your "qU'o"
"LAN eIIANOI, YOll m.y 'h"'~ I",nl wl\ll, ~ OrOl/II POlley lain lore., t>y compllllng I new 'I1IOllm,nt lorm and
"JI111"wr'g ItlQ Ut Intvr,"", IIn lilt new 11"11I wl/llJk. ,Hie. on l/lt /I," '/IllY 0." lOllOwlng OIJlIOC.pltnc, 01 tveh
""W IIn/\1I1",_,'1 IQlm
UAMIHATIOH 0' IHIUR,lHC'. lhl, "'Wf~ w". ~m/MlII on Iht ,.,Iif.. 01 LIlt IoIlowlflG ~a:
I tN, d",tl I". Grwp PolicV WI"""",,': 01
:t It'll ..,111 01 11'1. IIlW~ f'91~ 101 w~ "'~ tlM "'" P", If YOIoIllolllO PlV LIlt rtQlolilacl pramllJln: 01
, It", ."cj vllti;; "'W~ f';;rlQ4 W"'G *""11 Vlo'iA II' "'0 ~ . ~ 01 lilt "~INMO At~IOII. 01
. tr... ,I.'. (II r\J\4f ~.tII
Inawullcu on !!8ch InlUled Oependont wllllerollnata on Iha ..rll,11 of Iha following dal'"
1. when ~our InlUllnce I.rmlnalll; or
2. th. tnd of th. lnluranea Period Ihal d.pend,nlll no long.r ,n Ellglbl. OtPfnd.nl; or
:I. Ihlt enn 01 th. Inluranee Period for which premium hll bt.n plld. II you '.11 to P'Y lilt ,""u.d p1.mium IQllhal
Inlurud Dopandant.
T .rmmalion of your Inlurane. will be wllhoul pr'Judle.IO .nv ben.llt p'Vable 10110.. whk:h ,,"\IIrtel prlot 10 ',"f11nalilill
R~IN. T A TeMINT. It Ihll C.I\lllc... lermlna,.. btC.U" 01 flC)/\>f)tvm.nl 01 p1.mlum wIltn 1\ II M. " ""v be rtlnll.led
within 30 dayl from Ih. dl'. 01 lueh 'ermln.lIon bV p.ym.nl 01 all overdu. prtmluml ,nd .vidtnct 01 'nl"r.blllly
..1I11lctory 10 VI, II W. "qui,. II.
HOW TO FILl A CLAIM, You mUlt wrll. U. .boull cl.lm wllhln to dlYI .lIer I'" ,,"ulI,nc. 01 any loll or It two
II you cln Wa will provld. you with clllm lorml or W. will ..nd Ih.m '0 you wllhlh \I O'YI ,"" you 1.11 U. lboul
'ha tlalm. It W. don'I ..nd Ih. 10r"'l In III d.V'. you Cln Ilmplv ..nd UI wlltl.n prool of ,,,, to.., lilt prool mVII
lhow Ih. d.lt, 'h. ch.rlcler Ind ,ll.n' 01 Ih. 10'1,
Vou mUI' I.nd prool '0 UI wilhln eo d'VI III" Ih. dl" nl luCh 10", II you Cannol ..nd prool to UI wllhln eo <llyI,
you mUI' do 10 II loon.. you cln. Unl... you h.vI be.n ..g.IIV lneap.bl. olllllng Ih. prool 011011, W. won'I ",al'l
II 111111 hl'd Iller ona ya.r Irom Ih. 11m. 1\ Ihould hlv, be.n IlItd. You cln'l ,II" any legal to1IOI\ 1QIIl"11 UI un,ll
50 daya aller ~ou ..nil UI prool of 10.. .nd you CIO'I It." .nv ItgllactlOn .galnal UI 11IOI. INn a V"'I (I ytl'l
lor !louth C.rollnl ,.lldanll' Iller you hive "nil'" prool.
MISlTAUMINT 0' AOI. II you mlll'lt.d Vour .g., llIlmo"n'l plyablt undtt I'" Oroup "*y will be tIK.h..
tha premium paid would hlv' purehl..d II you, corrtCl Ig..
ITATlMINTI 0' INIU"AIILITY. Tilt aroup Policy, Iht AppllcltiOn lot IhIQroup"OIley and \hi Mtmbtttltv(ltlmfnl
form "a the compl.t. eont/lcl ollnlU/lnct. All It.l.mtnl. /NIdI by you "' OO/lIldtIN 10 "IV' bNn m. 10 \hi
bltll of your knowl.dgt and beUtf No l'I'.""nl can be ulld to VOId \11lllntulWt Of cttnv . oIlim unItIt tflallIt'-'Mnt
la IIUn.d by you. AIIII ~ ytllllrom 'h. t".cllv, d... 01 Inlurane. on IOV In.urad "If"". no t"I.ml/l1 mlllt by you
cln bt Ulld 10 VOid Ihll Inlul.nC. or d.nv I clllm.
PtlYlICAL exAMINATION' AND AUTO'.Y. WI." Our own ..pen... hlv, I'" rlghllO ,IIIIIN an IntulH ",,10/1
II oll.n II II lI..onllll~ rtqulred whll. I clllm II pending Ind to mlk. In .ulO\ltV In ,aM fll "'I'" whitt It II no1
lorblddan by IIW,
CONfORMITY WITH ITA1..TA1UTI.. AnV p.n 011'" Oroup I"olloy which. on "" I~ 0.11 01"" Ofoup""',
conllicll wllh Iht IIIIU'" 01 Ihl 1'1'1 whtr. I'" Oroup PoIloV WII C1t11V.rtd II chtnOtd 10 CllInlotm 10 IN mitIlmU/Il
Ilanderda 0' tholl Italul'"
Thll C.rtlliclt. ltP!acll Ind IUpell.. IIlV Cll\lllel" pr.vlOUtIy IIIlIId 10 you.
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J~'r~! 1 J J f'l.HPiHPJ. 1,.1: !.:r
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I illll! IJ 'II ~PII~~HIHflllhldil
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,oAN l.. AI.EXANDkR
""nllff
I IN nil COURT 011 COMMON ,..&AI OF
I (.'\JMIUIANO (l)UN'fY, PENNSYLVANIA
I
I DOt",n NO.
I
I
I
I "IVII. DIVISION. lAW
\"
CUN" MU11.JAL INSURANCC
OROUP
o.r......
COMPlAINT
1011I L AI.Ilan4tf th'OIlP lit, lnotllty Drou,lo.. OUrl/)' A atoll.lCllI "" torth the followlll,
OhM of "tIM:
Plalfl'lft'l JOM L, AlfllIm..r, 1110 bown II 10M 1" Itmutl, M a4tAlt lMlvldual
,..i4lll, II 22) 1211I .If.... N.w Cvmbtr11114. Cvmwlllld COlll\ty, 'fM~lv,,". 17070,'"
,..lIftItd hft maldtn name afItt ....11I 0' IIff hll.ttwt
2 o.rtttdtnl II CUNA M~IIIlI"tlIIlMt OIoup, I fOrpo,lIkin lIavial . ,riM!JaI pi... of
Iilltlfttt. II PO DOll 6', W..,,,ly. \Ow, 'OO11.{106I, optrllUlI..d _.lMlntllia..
('o"'motlwttllll "r 'fM~lvMI'
) 0.0". D 11''''11II dHf1H4 00 o...mt>>ff " I")
of OtOrlf P 'fItlllll had ftllllfK1td willi p,rfll4M. i"wP Itt. ~ff U ". "
mlll..1 'aR Of.".. .fIt'lttlItt, U... Colll\l)'. ,.,..,tvMi, rw . Ilf. IMWIIIff ,.titr.
u Nt ({1M ,It C.....llu.. No Pi*6UI ....., Cool/N' N\l. C))1.oUM
, Oto,..l) ItmIM"'~ l'I~ff It "'* iNfMn.,." IiII4ff tIM ~
6 n. ,.tuy wu . ml#f.ull tulrknw. .. w ..mMikf~ ~..
7 c~ of ~ .."' fV~ .. tIN .,.,. t;I N;Rf .t.. ~JrlJt TN"",., w.
..qlltl"d to b. ..nl by D.ftndanl. which h.. r.fII"d 10 pravld. a ~p)' af Ih. policy ta Ih.
"lainlllT,
. Th. Caron.r deltrmintd thlllmmedialt "u" af d.alh w.. ,arbon l1\anallld.
inlOlli"t.on
\I Otar,. 0, StIllu" wu faund in hil v.hi,l. In hil .arl.. 11'I.r b.ln, r.fII..d m.n 10
the marital habitalion II 22) 12th Slr"l. N.w Cumberland. P,nn.)'lvanll,
10 The mlllllff of dulb wu IOcldtnlal
II D,mand hu bHn madt by PI,inlllT I.ainlllh. D.ftndanl far Plym.nt of b.n.nll,
reqlltlun. application (ur Inllllanu, Plym.nt uf b.n.n'I, eopy af policy, and copy af all
infarmation ..latin, 10 lb. In,,,,an" policy, all af whi,h hu bHn r.f11led by the D.r.ndant.
12, PlaintilT I... ma41 dtmand upon D.ftndanl for lb. btn.nl. plyabl. und.r lb.
accidental "tlllllIIU conlflOt. ~Ich O.ftndanl hu r.fIIHd to PlY.
WIUUWI'Oltft, PlainlllT reqllfttl thi. Ilonarabl. Coun 10 tnt" j\ld.mlllt _,aln.1 P.f",eJlnt
(0' lb. lIlIO\lftt of"" ben.nll under Iht contracl, inl.r"I, and ~II. of lul\,
",."~~
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O \
lit: ,-t~
13 , I....
1 H hrouJal, Baq Ir.
DRDU ., OILROY . 1I0UITON, r.c,
4 Nonh IllnOv.r Sir,,,
Carti,I" PtnnfYlvlllia 110 U
'''1241.4''. 1111'766.1690
PAX' '71'71241,'221
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I IN '!'HI COURT or COMMON PLEAI
I CUMBlRLAND COUNTY, PENNIYLVANIA
I
I CIVIL ACTION - LAW
I
I NO. .e-ao. civil Tera
I
JOAN L. ALIXAND~iaintitt
CUNA MUTUAL INSURANCE QItOUP,
Detendant
IIO'fIC. ora tLD.D
TOI JOAN L. ALEXANDER, plalntltt and
JOHN H. BROUJOS, lequire, her attorneYI
you MI HPIBY NOTIFUD TO rILl A WRITTEN RI.PONII TO '!'HI
ICNCLOSID ANSWER WITH NIW MATTEI' WITHIN TWBNTY (20) DAVS FROM
SPVlel lIPlOr OR A JUDOMBNT NAY DI ENTERlD AGAINST YOU.
ep en . ore
Attorney 1.0. No.
J.... ,. DeAngelo
Attorney I.D. No. 6a377
100 ,1ne &traet
P. O. BOIC 1166
H.rri.burv, PA 17101-116.
(717) na-IOOO
Attorn.y. tor Detendant
CUNA Mutual In.uranae Group
Dated' Karoh 12, 1'"
v.
, IN Tltl COURT or COMMON 'LIA.
, CUMllJU..AHD COUNTY, PINNIYINANIA
,
, CIVIL ACTION . LAW
,
, NO. .a-aol Clvll T.ra
,
JOAN L, ALlXANDIR1
P ainUft
CUNA MUTUAL INIURAHCI GROUP,
D.t,ndlnt
All.... .Ift ... Ill""
tg a...ee ponlllll
1, AclIIltt.d.
a, Ad.ltt.d,
" Ad_itt.d
4. Dlnl.d II .tlt~. A Group Aoold.ntll D.lth And Dl.....
beraant 'ollcy (N'olloy.) WI' l'lu~ by CUNA Mutull In.ur.ne.
800l.ty, ..10 Mln.rll polnt Ro.d, MI41.on, Wleooneln '3701. Th.
polloyholder 1. M..blr cov.raq.e Group In.urlno. Tru.t. Th.
polloy nuaber 1. 111-301-01IJIM.v. I.. A true .nd oorr.ot oopy
ot the 'elloy 1. .ttlohed her.to I' Ixhlblt NAN .nd lnoorporlt.d
h.r.ln by r.ter.noe. rur.ulnt to the 'olloy, I C.rtltlolt. ot
Inlur.no., Group AoolcS.nt.l D..th and Dle..aber..nt (NC.rtlfl.
olt.N) w.e le.u~ to aeort. D, 'eautl. A tru. Ind oorr.ot oopy
ot the C.rtlfloat. 1. att.oh~ hlr.to Ie Ixhlblt NI. .nd lncor-
porlted her.ln by r.t.r.no.,
II, Adalttlki,
., Ad_ltt.a wlth ollrltloltlon thl' the ,olloy Ind e.r-
tlflclt. Ir. wrltt.n doou..ntl Whlch .pe.k for th....lv...
7, D.nled. Thu..n 1M) "",Ut. ,Iy.bl. Ii"'" tM 'oUo)'
.nd C.rtUll:.tI nl.t.a to tM duth (It OM..,. D. ...,ta. 1M
C.rti,iaat. provid.d 111,000.00 in Aooidental neath CovI,a,1 on
the li,. 0' 0.or9. D. '..uta.
It Ad.ltted ln plrt Ind d.nl~ ln part. It 1. adaltted
thlt the d.ath o.rtt,loat. .tlt.. thlt the "I..~llte cau..
(t1ntl d1..... or oondition re.ultlnv in death) Clrbon Monoxlde
Intoxioatlon," How.v.r, the death o.rtitioat. .how. that the
..nner of d.ath "oould not be det.r.ined."
I. Ad.ltt~ In part and denl~ in part. It i. adaltt.d
th.t Oeor.. O. 'e.ut. waa rouna d.a4 ln an .uto.obll. 1n a
'.r.... AI to the r...lnint Iv.r..nt. ot 'Ira.raph ., Ift.r
r..80ntbl. lnv.atl,ation, OIt.na.nt i. wlthout knowle4t. or
intoraatlon .utrlol.nt to allow lt to adalt or d.nv tho.e av.r-
..nt. and the .... .r. th.r.tor. d.nl~.
10. o.nl~. Th. d.ath o.rtlflo.t. and the OOfon.f'l vl.w
.tat. th., the ..nnar ot d..th Gould not be d.t.r-ln~.
OItand.nt'. anew.r to 'ara,r.ph . I~ve i. lnoorpof.t~ her.ln by
uranno..
11, A4alt\t4 with 011,1tloltlon, It 1. '-'It\14 thlt .
"..."" tor ,.y..nt ot """Ut. hat HI" ..4e Ind .lnll4,
'lalntltt hi. ...n provl." wlth relev.nt, dl~er.ble deou..nt.
.. requltN.
U. Adal""'.
tlNIAltO.., o.ten41nt r"\M'" 'hi' ;\149,,"\ lM ."..,.. 1"
1'. t.v.. a", ...1~' '1,1,,\1" tot.,ty, vl'b ...."
'" , ..
IJEW MATTIA
1'. Def.nd.nt'. an.wer. to p.r.vr.ph' 1 throuvh 13 .bov.
.r. lnoorpor.ted her.ln by r.f.r.nce.
14. Pl.lntltf h.. t.il.d to .t.te . ol.i. upon whioh reli.f
..y be vr.nhd.
lD. pur.uant to the 'ollcy and C.rtlfic.te, true and
correct copi.. ot which ar. attach.d h.r.to as Ixhibits "A" and
"8", r.sp.ctiv.ly, and inoorporat.d h.r.in by r.t.r.nc., ,lain-
titf i. not .ntitled to ben.tits and Det.ndant i. not oblivated
to pay ben.fits.
It. Th. death certiticat. ehows that the ..nner ot death
.oould not be deterained."
17. 8enefit. ar. Ply.bl' under the 'olicy and Certific.te
only where death r..ults tro. an accident.
11. The d..th ot 0.or9' D. le.uta was not the r..ult of an
.coid.nt.
11. It i. beli.ved, and th.retor. .v.rr.d, that O.orv. D.
I..ut.'. blood .lcohol lev.l w.s 0.21.
30. Th. Policy and certitic.t. oont.in oov.r.v. exolusion.
whioh exclude cov.rav. in this 0.... Ipecitic.lly, the ,olicy
and C.rtlfio.te provide th.t,
w. wl11 not P'y I ben.tit for Iny 10.. to an
Inaur.d r.r.on clu..d by or r..ultinQ tro.,
1. auiolda whl1e a.na or In..n., or
J. int.ntionally aalf-intliotl4 in'ury, or
,. daGlarl4 or un4aolara4 war or any lot th.r~f, or
- ) .
.1r tr.v.l .. . pl10t or orew ...blr, or
op.r.tln, . aotor vehlol. whll. intowlo.,.d, or
rldln, or drlvlnQ in .ny klnd of raG' .. . prof.l.lon-
al, or
oo..lttln, or .tt..ptlnq to oo..lt a f.lony, or
volunt.ry Ue. of any dru" ..dlolne, or ..d.tiv.,
.xo.pt .s pr.sorlbed by e phy.l01an.
WHIRIFORI, D.fendant requ"t' that 'udW-.nt be ent.r.d ln
it. f.vor and .,.1nlt Plalntlff toq.th.r wlth ooet..
4.
I.
t.
.,.
I.
~--
'p .n
Attorn.y .D. No. 41a..
.:r.... P. DeAnQ.lo
Attorn.y I.D. NO. "'"
100 ,1ne Itn.t
P. o. Dox U66
H.rrl.bur",A 1110'-11"
(111) na-.ooo
Attorn.y. for Def.ndant
CUNA Mutual In.urano. Group
DetHI Mlroh 13, I'"
. << .
f.
laOUl' ACCIDfNTAL DEATH & DISM04BfRMOO' POLICY
T.bl. 0' Content.
T'nI' and Dt'lnl~lon.
"n"11 ProYlaton.
..",flU
bclu.lon.
T'nlln'tton 0' Indlvldu.1 Inau,.nc.
How to ,,,. , ChI_
"..lUll Ch'P'9I' I"d PlylIItnt
T'nlln,tlon 0' thl. '01tc1
I
J
I
.
7
.
.
.
.
QJHA MlT\IAL IMSUAAHCE SOCIETY
"10 "In.ral PoInt Road
. ".dl.on, WI,eon,ln 53705
Group 'oHcy "__'I
Pollcyhold'r!
'01lc10'&tI
Dellv.red tn ,tat. 0'1
Tht. 'ollcy t. la'u,d In con.lderltlon 0' the Application 'or the PolIcy
Ind the plyment 0' thl prIMlum ~h'n It I. dUI. Thl. Pol Ie)' provld.,
In.urlne. 'or .ccldlntal d..th .nd dl,-.mb,rment 0' the Inlur.d P.rlon Ind
the In.ur.d DIP.ndlnts. If Ippltelbl..
Thla 'olley tlk.. I"ICt on the Pollc)' 0.'1. Thl 'Ietlonl I.t 'orth on the
'ollowln, p',Ir Irl p.rt 0' thl. PolIcy. Thl. Pol Ie)' I. ,ovlrnld b)' thl
II'" 0' the .t.t. In ~hlch It I. dlllv.rld,
CUNA t<<JTUAL INSURAHCE SOCltTY
/" ,.....;,.,f~~t, ,',',._'1'....,.
\ '- ft. '''' ~ , '; I, ': ,1
..h~!; .' '.' .
JUl 18 1906
Gr~Oll? P. c. :!
""IlUrlN Ice I:'CPlJi i I,\~' ',IT
STATE 017 wt.SCmV;1I1
Pres Id,nt
Ster,tl'y
Notlc, to PollcyhOld.r.
ThI SocI,ty will hold. ,llnnl.1 O'"4r,1 ll.ctlon In Madl.on, WI,con.tn tn
..cll ,v.n-IIIM.r." y..r 'or thl ,Iectlon 0' OlrICtor. '114 any otlll, NU.rt
to ... .",ov.d "y pollc~"'ld.r', It wtll b. 11I14 on the tlltrd VtdJlt.4UY 0'
April ...tw"n th, hour. 0' 10:00 .... and 4:00 p,.. ~nl... pollcyhol""
.r, 0'''",111 ftOtt,It4.
It JOlt *" ''', a ".11.\ \0 yoU pili" "rU. tUNA Mutlfll Ill'lff.M.
$oct'l/, "10 "'MInI 'otll\ .o.d. ~.O. 101 )11, """0.., lIlt(OfI.11I U'DI It
I.,t\ :0 4.,. '" a"..n<..
TERMS' DEfiNITIONS
A' u,.d In thl, Polley th.a. wordl .n. t.nI' ,h.'1 hlv. the fo"owln,
lhO.n I n,"
C[RTlfICATE
..,,,a the C.rtlflc.t. of Inlur,nc. lalu,' to I
peraon tnlur.. un..r thl, POlt,y.
"1"1 (1) the Illglbl. "'-b.r', apoul' who la und"
.. y..n of .g.\ Ind U) the lItllbl. l4ItRtI.r',
uRNrrl.d d.",nd.nt chltdrln und.r 1 y..rl of Ig.,
lllglbl. D.p.nd.nt .ho Nln' ul1llltrrl.d chlldr.n
b.twtln the IglI of 18 .nd 24 yura of It' wIIO .r.
full.\tllt ttud.nu .nd who Ir. d.p.nd." on the
ElIgible "fIb.r for.t I..,t 501 of th.lr ,upport
.nd ..tnun.net.
..,nl I ..mb.r of the cr.dlt union who tl oy.r 18
Ind und.r 69 y..r, 0' .g..
..Ina .1ao ,h., h.r or h.rl.
..Inl I l.wfu'ly run tnltltutlon for the c.r. .nd
tr.ltlent of ,Ick or InJur.d p.raon, und.r the
dlr.etton 0' . ,t,ff of Phy,lcI.n,. It IUlt h.v.
or"nl..d f.cllttl., for ..die.' dlllnoall.
tr.ltlent .nd ,ur,.,y, It .uat h.y. '.hour
nurllny l.rvlc'l. It dOli not ...n.n In,tltutlon
prl..r ly or9.nl,.d to tr'lt thl lve'. 'rul .ddlct,
or .1eohoHes. It don not Mln . nuraln, hOlll.
cony,l,lc.nt hOllt or I ,1.1,., Inltltutlon.
..,nl I p.rlon 1~ltt.d to a hOlplt., .. I r.ltd.nt
~d p.tl,nt .nd for who.. conflnlMtnt th. ho.,lt.,
Ch.r". It I ,.,ul.r Ind cu't~ry d,lly chlr" tor
rOOl Ind bOI rd.
.,m bodily InJwry cell'" by In lCehl.nt occurrlll'
Whl'. thll PolICY I' In tore. .1 to th, In'ur.'
',rlOft .n' r,,"1tln, 'Ir.ctly Ind Ind.p.ft6entl, .t
.11 O~.r C.UI.I In Ivt' coy.r.d by thll 'ollcy,
...n' In Cll9lbl. Of",,'.ntl
I. t.,. whew tilt Intwr'.....r h.. c..,l.tt4 III
,nr.'1Mnt '0'" .nd h.. ."ltd to ,., tN
',....11/1I Ch.r,.,. .nd
I. """ h.. b"" leu't'd Ity III tqr cov,"" 1/."
~tl "llcYI .nd
" .,." ".. 114\ "'II t,""~t.d ft,. COYlr.,. .,
~h ,.Hcy I" ,uord'JI.C' wI..,. "" ",..I",UM
'rovl,to"" ,NI
.. ... It Mt .t~",h. 1.111'" It '" CU,lltl.
....., q, .t ,. U t,I.'. o.,."tH,.\ tmH' t~h
"H~1.
EliGIBLE
D[PENDENT
ELIGIBLE MOIlER
.
liE, III", OR HIS
IIOSPITAL
IN.PAmMT
INJURY
I NSURlO
DlPUIOlfCT
.
ILICtRAL PaOVISIOMS
~IICISmTlYC U'USC Of THI: 'OI.lCYtIOLOlR. W. Ny 'art. to
f.l~rl' y~ '.r your .dMlnlltr.tlv. .apenl' In confttCtlon wIth your
p.r'onalnc. 0' the ,,,,,crlbtd dutl'l ., th. 'ollcyhold.r.
AH(NDMf~TS. Thl' contr.et ~y b. ch.ng'd .t .ny tl.. wIthout thl
conl.nt 0' th. perlon, who ,r. th.n Inlur.d. A ch.na. c.nnot t.k. .WIY ,ny
rlghtl 0' th, Inlur.d p.r.onl whIch .rOl. prIor to the tl" the c.h.n9' W.I
MId.. No eh.na. .111 b. v.lld unl.II tlaned by th. pr.,ld.nt. . vlc.
pr'lld.nt, th. I.erlt.ry, .n .llllt.nt I.cr.tary, or thl .ctu.ry 0' the
Socl.ty, An .a.nt 0' the Soel.ty c.nnot ch.na. thll contr.ct, w.lv. .ny 0'
It I t.,.. or -.k. pro.lt.1 th.t wIll b. blndlna on the ,OCI.ty.
CllNleAl lRAORS. Cl.rlc.l .rror, In the k,.,lng or r.portlng 0'
r.cordl wIll not Inv.lld.t. Inaur.ne. oth.rwll' v.lldly In 'ore. nor
contlnul Inaur.ne. oth.rwlt. v.lldly t'Mlln.t.d, Upon dltcov.ry 0' .uch
.rror, an IdJUI~nt 0' prlml~l. It Iny, wIll b. Nd..
Tllf CONTRACT. Thlt Pollc1. wIth th. Appllc.tlon Ind .ny .tt.eh.d
Ald,r or lndor....nl. II th. .ntlr. Inlur.ne. contr.ct.
'MlOIT UNION .(COIDS You th.11 ~k. av.ll.bl. to UI, on r.qu..t,
'"y 0' 10yr book. .nd r.cordl pert.lnlng to cov.r.,. und,r thll PolIcy.
PAlA RfQUIRto. You wIll 'urnl.h tn .rtttng on 'OMIt t.tlt'.etory
to UI lueh In'o~tlon .t MlY b. r.qulr.d 'or th, .a-tnl.tratlon 0' thtt
Inlur.ne., Thl. wIll Includ. d.t. on Intur.d P.rlon. who .r. b,eOlln;
Inlur,d, whOI' In.ur.ne. It t.,.ln.tlnl. or whO .r. eh.ngln; to . dl".r.nt
ph".
("(CliVi DATI 0' CQYlAA4l. Th. In.ur.ne. on anI (llglbl. KtMb.r
.nd hI. 11Iglbl. Dtptnd.nt. I' .ny. wIll t.k. "'.ct on tn. pr..l~ du.
d.t. 'ollowl"1 r.C.lpt 0' hil .Ign.d Cnroll..nt 'or. by tht cr.dlt union.
flAM CHANel. An 1"lur,4 MtIO.r ~1 ch.nt. Pl,", whll. thl. PolIcy
II in 'ofe,. by COMPI.tlnl . fttW Cnroll,,"t 'ona .nd .ubllttl", It to th.
(r.dlt unIon, In,u,.ne. on th, n,W Pl," wIll t.k. "'eet on tht n..'
P'MIUII 4v. d.t..
lVlOrMCC Of IICSUMIILln. W. -'1 rtqulr. trOlll .n IItllbl. ...."
.n4 .nl " hit Illllbl. Dt"nO,"tl, .vld.nc. 0' IlItwr.blllt1 ., p.rt 0' th.
,n,oll..nt p,oc.dur..
GAACC PIRlOO. Thl. Pollcl h.. . 31 d" ,r.c. p.rlod. Thl, ...n,
th.t I' . "..Iu. I. not p'Id 0" .r be'o" t~. Gtt. 't I' due It", b.
".14 durin. tn. 'Ollowln. 31 41y" OU,ln! tn. .r.e. ,.,Iod th. ;oIICI wIll
a"1 In for,.. the ,r.e. ,.rl.d w. I not .,ply I' th't 'ol'cy It
'".'n.t.4 ., tht Socl,ty .r bl the cr.4lt unltn.
J"'~JfJ'AlllIJ' t~l. 'ollcl .~II not .. cont.at'd _ft., Z y..r.
,,~ tlt4 (tf,nh. O..t, ne.,t for 1tqA"'PlMt .f ".1".,. 110 un","t
...". ~f .,. 1~''1't4 ,,,,,,, NY .. 11114 t. vtld I'tll""" .r to ""1' ~1,1.
.hl.~, .~. .t.~"t 'I IlfA'd ., _._, Att", "'" ".. tae "'fetlv.
Of
O.tl ot Insur.nc. on .ny Insured P.rsont no statement ..d. by him Cln b.
uI.d to void this Insur.nCI or d.ny I Cl.lm.
INDIVIDUAL CERTifICATES. W. will IIIU. to you, for dlllv.ry to
I.ch Insur.d MeMber, I C.rtltlelt. dllcrlblng th. Insur.nc. cov.r.g., how
b.n.tlts wIll b. p.ld, and th. rights .nd prlvll.g'l und.r th. t.nlS ot
this Policy.
HISSTATtMlNT Of AGE. It th. .g' of Iny Insur.d M.mb.r h.1 bl.n
mtlltlt.d, .11 I~unts pay.bl. und.r thll PolIcy wIll b. luch II th.
premtum p.ld would have purch.l.d It hll corr.ct .g..
RfINSTAT[H[HT. If .ny c.rtltlc.t. which Is IIIu.d und.r thll
PolIcy t.nRtn.t.1 b.c.uI. ot non-p.yment ot premIum wh.n It II du., It..y
b. r.lnstal.d within 30 d.y. frOlll the d.U ot luch t'l'IIIllI.tlon by plylltnt
ot .11 ov.rdul premiums .nd .vldenc. ot Inlurablllty ..ttst.ctory to UI, It
we requ t r. 1\.
RENEWAL OF POLICY. Thll Polley II Ilsu.d tor I t.rm ot on. YI.r
but may b, rentw.d with the conl.nt ot the Socltty ..ch y..r th.r..ft.r,
STATEMeNTS Of INSURABILITY. All It.ttment, m.d. by any p.rlon
rel.tln, to hll Inlur.blllty Ihall b, con,ld.red to h.v. b..n ..dl to the
b.'t 0 hll knowlldg. Ind b.ll.f. No It.ttment ..y be u,.d to cont.lt
Inlur.nce unl.IS It II In writing .nd Ilgn.d by th. p.rlon m4klng th.
.t'I...nt .nd unllll . copy h.1 b..n glVln to hIm,
PARTICIPATING . DIVIDENDS. At the Ind ot th. I.cond y,ar, and.t
th. ,nd ot Ilch lubllqulnt pOliCY y..r, thlt policy, whll. in torc. thlll
p.rtlclp.t. In th. dlVlllbl. lurplul, It .ny, .1 .pportlon.d by thl IOlrd
ot Director..
,
.
.
UNf,ns
Whll. thll 'olley II In 'ore.. Inlur.d '.rsonl '1" eov.r.d 2. hours a d.y.
365 d.ys I ,"1' 'V.lnlt .eel.'ntl In ~h. courl' 0' bullnels or pl,.sur..
Cov,r." Includes (but II not II_It,d to) .celd.ntl wh,th,r On or 0" th,
Job. oeeurrln, In th, hoee, tr.v.II", as . PlII.n,.r bl tr.ln. alr,I.",.
automobll, or oth.r ,ublle or ,rlvlt. tr.nlport.tlo", Th, b,n"ltl
,rovld.d und,r thll '01 leI II" ,.y.bl, In .tdltlon to .ny oth,r Inlur.ne.
~Ich ..y b. In "'.et .t th, tl.. 0' .celd.nt.
I' .n Inlur.d ',rlon lu.tllnl . 101. wIthIn 365 .'11 ,'t.r th. d.t. 0' .n
.celd.nt. w. wIll "y In on. IU., th. Indlc.t,d ,.rc.nt.,. 0' th. 'rlncl,.1
Su. .I.et.d 'Orl
!I!!!.U
LI', 1001 101
loth H.ndl or both ,.,t 1001 101
11911t 0' loth ,,'1 1001 101
On, h.nd .1Id on. 'oot 1001 101
On, h.nd .nd sl,ht 0' 0"' 'y' 1001 101
On, 'oot .1Id s I,ht 0' on, '1' 1001 101
On. Mnd 01' on. 'oot or
.I,ht 0' on. .y. 101 'II
S,tleh or h,.rlll' tol 'I'
ThUiO Ind Ind.. In"r 0'
II" h.nd 211 Irl
Only on, "".'It, the 1.r9.lt to whIch the Insurld '.rtOIl II '"tlt,.4 to.
tl ",.bl. '01' . I 1011.1 r'lultl". ',0. OAf .ecld'"t.
Dl'UtOIIlT ClIlLOAlII lUlU IT. 1'," IIItur.d .....1' .IM" tllt ,..U,
'1'11 .lId 101'1 hll II'. In '" .ccld,nt. w. wIll ", tl,ooo t. hIt
k""I,llrl 'or .ach child who h .n IIIIIIrld o.,.n4tllt on tllt ftte " tilt
.celd'n'. ,. flllt .."ltH It In 'ddl"," to .11 otlltr bene"U "I'bl, t,r
Ion 0', lit. 0' .11 I nlUrf" ....., IIIId.r tilt. ,.lIC1.
,',
GOI,.DlII MI ,.oUCTlGH. 1"11 III'III'.d .....1' or lilt '"lur1d .~..
,U.'Wf1(,'7O"W11Il' Illlu,d! coY"'" Nl COII"llII. It lon, It th, '....1..
II f"d, ,"d both th. "lle ~Ullt ,114 thf ',lncl,,1 tu. wIll.. l'.fijC.d '1
'01 oWl! '
l"~ "".~;/ to .,"'"
.....t
I, ,~,."..tt.IAlfllt 0' .t. 70, tilt "'"11' .f IlIlu,.ne. II ,.4wc.d '1 1011
'C,II(_ .
" IIH1! nUlMotllt of ... 7. .114 '''-'''''11'. t/lf MIOl#Jt /I' ""'1,'11('
,..,Inlllf II '",tllt, ,.4uc.4 ~ 161.
N1NHAL CoWl ....'n. It j"~'l .fllut ." '''.11'.4 't,tM .. ..
(IMU",. Ill' ~,It.' It ." t"'MU,,, .1t.11t OH ,", of '" Mtt ,f tN
.ulm'. ... ...,. .". i'j . ..'It .f " .f ,.... 1".11'14 '.mll', "t~j"l _
,~, "tell Ml _.t. ,t ..,.ft.....,. ~ ,. . ...... ....Ill .f U,. ..'
.
JI1'LU~
Lon 0'
rOI
'01
201
'01
'01
'01
101
101
II
.
.
~nth. Th. confln...nt ~It b. for a p.rlod of lOr. than 7 day.. '.n.fltl
wIll b. ,aleulat.d fro. the flr.t day of ,onfln...nt IlId wIll contInuo for
I' lon, .1 the Inlur,d P.r.on I' .0 conflnld, but for not ~r. thin 12
~nth, n Iny on. p.,lod Of confln.~nt. 'or a p.rtlll ~n'h. .Ich dally
b.n.flt wIll ba .qual to I/JOth of th. ~nthly b.n.flt.
IHflATIOH GUAAD. rich Inlur.d MfMb., who h.1 .I.ct.d In addItIonal
a~unt of Inluranc. (PrIncIpal SUM), wIll b. cov.r.d und.r th. Inflltlon
Gu.rd b.n.flt. rv.ry two 1.arl, on the ,nnlv.r,ary dlt. of the In.ur.d
l4Mb.r'. .nroll~nt, hla orl,ln, 'IlOU", of Idd.d (ov.rl" wOl b.
lut_tlully Incre...d U. lhh b.n.flt wtll (onttnu. to Iller.... the
Inlur.d MfIOtr'l cov.r.,. I' lon, al h. r...lnl IlIlur.d und.r the pro,rl.,
or ulltll hll cov.ra,. hal b.. II Iner.a,.d a tull 'II. Anl Chili" In
PrincIpiI S~ or plln typ. wIll b.,I" I n.w p.rIOd. I' r.llt.d to hI.
b.n.flt provlllon.
8fHf'IC1..', Ulll.la th, lnlur.d M,mb.r ,.11, UI oth.rwll', hll
bln.flcl.ry und.r thlt Pollcl tor Inlurlnc. p.y.bl. for lOll of Ilf,1
.
I. on th. d.lth of the lnlur.d ""b.r wIll b' hla IpoUI.. It llvln"
oth.rwl" hit .nu"
I. on the d..th of the 'nlur.d ~.r'l lpoUI. wIll be the lnlur.d MfMb.r,
If lIvIng, oth.rwl.. the .at.t. of th. ,poUI'1
J. on the d,lth of th, tnlur.d chlldr.1I wIll b. th. In.ur.d KlIO.r, tf
\lvl",. other.l.. hit 'poult, If Ihlll', oth.rw... th. ..t.t. of the
Inlyr.d chlldr.n.
CMMGI 0' IPlftlC1AAY, The ""ur,d ....." hit th, rl,ht, whO.
thlt Polley I. In forc., to ch'''I' ht. btn,flcl.ry wIthout (Onl'"' of Ih.
b.n.flel.ry, by wrltt.n r,qu.tt Oil 'hi fo~ for 'hll ,urpo.. luppll.d by
ua. The ch.nl' will ,.k. .ff.ct wh," .n40rl.d on hi. IlIdlvldull
ur,I""" .t OIlr It-. OffiCI. Upon such .ndor....n'. ,he ch./lI' wll1
r.llt. blck '0 and 'Ik. .ff.c' .. ,f 'h. d.t, h. 1IIIIId th. r.qu..' wh.'h.r
or not h. II llvlnl ,t 'hi tl.. WI r.c.lv. tftt r.qU'lt. Any r.qu.lt fO. r
Chlnt. III bt"fflcl,rl will no, .tt.c, ,ny pa~lIt ..d. by ul blfor. WI
r.c. vld hit "4I/.lt. ,
UC&.US10lQ
w. will Att PlY I b'Rffl' 'or '"y I... t. '" l"Iyr,d '.'Ion elul.d b1 or
'tluHIIII ".,
I. tlllel41 whll' "'" .' Inu",. .'
If 1""""11II11, ..1t.11I111.,,4 InJ"ry. or
). 'tel,r,4'r "114'41,,,4 w" or '''I .et t~,..,. .,
.. ,I' ",.,1 ,t . ,'1,. " crtw .....'. .'
t, .""'1,,,. ~'" ..~Icl, ~II, 11I,..le'\l4, 0'
tf "41",., 4".llIt III '"Y kln4 ., ,t<' .t , "O"II'~', "
7. C~I"'IIf.,.t .-,tl", ,. ,~I, . "lOftY. .r
I. 'o'VJI"', lI" " "1 4'fIII. M41c''''', ,r ...."... uu,t " "..ctlk4
., . """4"11.
.
,
, .
1t0W 10 filE A ClAIM
You mul\ writ. UI .bou\ . cl.l. withIn 20 d.y' .ft.r th. occurr.nc. 0' .ny
1011 or .. 10011 I' you C'". w. wIll provld, you with cl.l. 'o",I'.or WI
wll1 ..nit thM to 10U within Ii d.YI .ft., you t.1I UI ,bout the cl.la. "
WI dOIl't 1.lId th. 'orm. III .1 d,y.. you C'" 11,,11 ..nd u. wrltt," proof Of
the 1011. Th. proof mult Ihow th. d.t., thl ch.r.ct,r ,"d ..ttnt of the
lOll.
You mu.' I.nd proof to UI within 90 d'YI .ft.r thl d.t. of Iueh 101', If
you c.nnot Itnlt proot to lit wlthlll '0 d'YI. you MUlt do .0 'I 10011 .. you
c.n. Unl.l. th. Inlur.d P.rlon h.1 b..1I 1"'llf IIICIP.bl, of '111nl the
proo' 0' lOll. w. won't .c,.pt It If tt It , 1.1t .ft,r Oil' {..r 'ro. the
tl-. I' Ihould h'v. b..n ,Il.d. You or th, l"Iur'd P.r.on C'" 'It.rt '"1
1.,.1 .ctlon .,.In.t UI un'll 60 d.YI ,'t.r lOU I.nd UI proof 0' lOll .nd
you C.II't It.r' Iny 1'9.1 .ctlon .,.Inl' ul .or. thin ) y..rl .ft.r you
h.v. ,,"t th. proo'.
PAYM'NT 0' C~MS. lh. b.n.'lt 'or lOti 0' lIt. will b. P'l.bl. III
accord.nc. with the b.n.'I,I.ry d'IIQn.tlon .nd 'h. p'ovl,lonl r.IPletlng
luch p.ymell' which ..y b. III .'f.ct .t th. tl.. of p'~lIt. All othtr
btn,'ltl will b. p.y.bl. to the Inlur.d ~.r.
PHYSICAL UNlUIAflOItS AHD AUfOPSY. W., .t ou, own 11""11. hIV'
the right to ....tn. '" Inlur.d ',rlOIl .1 o't.n.I II r..lolllbly ,.qulr'd
whll. . cl.la II p.ndlll' .nd to M.k. .n .utoPlY I" C.I. 0' d..'h wher. It
II not 'orbldd," by l.w.
PIlOUlIt awtGlt NIO 'ATMOO
Pr.aIWlI to' thll 'ollcy will b. p.ld to ut In .dv.nc. on . q~rt.rl1
bull. Th. ..\hod of pr..IUII pa1'llntl NY be culltfd to 'MI,"nU.11, .r
.nnu.lly by .'r.....nt b.tWl.n th. 'oltcll101dtr all4 Th. Socl.tl. ''''1-
wIll b. ,.lcul.lld on th. ba.l. 'tat.d III th. Schedul. of P,,,IIIMt thown fn
your Appttcatlon.
W. lI'v, the rltllt on .nl p'''I~ dut d.t.. if ,Ivln, .dv.nc. w,ltt.n notlc.
to you. to ch.n,. tll. pr"IIIM rlt., ,pplle,b . " Inlur.lIC, provldtd un4tr
thll PolICy. A cII.ng. III pr..I~ r.t., wIll /lOt b. ..61 .or. ott.n than
one. durIn, 'nl policy ,..r.
n"'llCA fI 0fI 0' 1lt II rellCY
11111 'ollcl will ,ut~tlc.ll1 tl,.ln.t. If .nl "..111M II /lOt p.ld wIthin
the Gr.c. '.rl04.
1hlt Pollcl ..y" t,,..llIft.d It '"I tt.. by ,lth" tM 'MI.ty or bl thl
cr'dlt unl.n wIthout ,r.JylfIC' to '"l ..tttl~ ,I,tal. W,'tt.n IIItle, ,t
tnt.ntltftl to t,",llIft. tllll ,.llcy MUtt b. ,lVIII, 011I ",ty to tht '~"
.t I.,.t JI -'1' In .dv,nc,.
If thl. ,.,Icl t,",I"".., lOU 1h4,1 b, ",bl. "vt fo, tht "1'Wnt 0' ...
,'M'Iia' ."..c" N.. Nt Nf" Il!IClv4t4 'Il .'" ".... ,.,.""
.
~
Madlaon, Wllconatn
'011OII.. Ct 11 rornt.
~tl\ij1[~ m~~rVD
JUL 18 1986
GBuuP IX & :-1
j....UHANce OEPAR1MUH
RlATe OF WISCOt~SIN
CUM MUlUAL lNSUlWlCE SOCltTy
[NDORS04UCT Of' COV[RAG[
In cOlllfd.r.tlon 0' th, premIum, thll [ndor.ement I, Ittlch.d to Ind ..d, I
plrt of Group A~cl4entll O.ath Ind Ol,memb.rmlllt PolIcy No.
Th. SCh.dul, 0' ,.n.'ltl In th. PolIcy II lmelld.d to Includ. th. followlngl
llch fll,lbl. ~.r who hi' ,"roll.d for Inlurlnc. Ind I. Inlur.d ulld.r
the t.MlI of thl, Policy wIll b. Inlur.d for th. S '1.le AmoUllt ot
Inlur.ne. 011 I nOli-contrIbutory bl.ll. Thll 1..lc ~Ullt will b. In .tt.ct
tor I p.rlod 0' 011' Y'lr trOM th, Eff.ctlv. Olt. 0' th. llllur.d Mtmb.r'l
eov.'I" .nd will b. III 14dltloll to the .ddltlonll lmount of Inlur.nc.
(Prlnctpll Sue) .1.ct.d by the In.ur.d Helb.r.
IN W"NESS WHlR[O', CUNA Mutu.l In.ur,"c, Socl.tl hi' c,uI.d thl.
Endor....nt to b. ...cut.d by ftl duly ,uthorlz.d offlc.r. thll
d.y of , . I' . Thtl dlt' t. the Eff.ctlv. Dat. .or trirl
[lIdorl...nt. ---
CUM MUT1W. INSURANCE soclm
'rllld.nt
AUtlt1
Stcrttlry
Ari'l. ..,fit",
.
Ile-)O\.O'U-,
-- "'-""--'.'~-
. ,,(t)
9U1'."'CA'l'Iptf
I, J.th A. Anderton, A....Unt Yio. .r..ld.nt 01 Crectit Unlon
In.ur.nol D1v1.1on lOf c.ntury co.panll' 01 Aa.rlo., .n .II111a'l
01 CUNA Mutu.l Inaur.nol 'OO.ltV, do h.r.by 0.rtl1Y .nd .tta.c th.t
'hi IUloh.1I h.rlt" 1. . true Ind ooruot ,plol..n oopy 01 thl
oroup Aoold.ntal Ollth .nd Ol....ber..nt C.rtlllolt. 1.luld to
O,Oft. D. ...ut. on '.~rulry I, 1..'. Und.r polloy
Ho. &1.-)OI-OI.J/"lv..' by euHA Mutu.l In.urlne. .ool.ty.
~~+.f1 (l ,a1fJi.r/
J. A. A .r.on
't.tl 01 IOW~ l.,.
countv 01 e\J~H'(,J >>
'ub.or1N4 and orn Nlon .. on thi.
J<<.;It. II 'I of '" , nut.
Not.ry u~llo, ~lt~~ county, IOWI
My Cou1nton ..pln. _~f/~#'17 ·
CUNA MUTUAL INSURANCF c;nl".n'V INC.
PO Bo. 6', Wav"ly lo""a WllT7
(I dllcd WE. US or OURI
CERTI'ICATI 0' IHIURAHCII
Group Aocldtn'e1 o.a'h Ind DtMl.mbtrmtn,
(Pl.... reI" 10 bolh Policy Number and c.rtlflca"
Number In any oommunlcallon COI\CIrnlng Ihl.
In.U/anct.)
r-
-,
INSURI![) MEMSI!A
GEDlJit.1l StMUTA
2EQlrrMifRClHo PA 17010
L_
.J
POLICYHOLDER:
HAMI 0'
PARTICIPA TIHO
AIIOCIATIOH
M[M8f:R coveltAGe. "UI'P
l~linj:~~fA~fO nOfUL
IHSUItAHCe ,,,un
GROUP POl.tCY [ I
HUM'." . 'a-30'.Q'NJAtv...
,CHIDULI
e,.iiFicA" """J ;~ ' 'FeCTlve 0 ATE
OIIOI/IJ
0066".' " 1:101 AM. llandlld T1mI allllt
__"___ .~RllL"ll ~,u n' Itl
PRINCIPAL 8UM
PREMIUM
I ..10 OUARTERLY
Pl.AN 01' INSURANC!!
IUlOO .
S..1o Amounl (NotHlonlrlbu\ol'f):
Addlllonal Amounl (Conlrtbulorv):
.... ,W!'Il;; amounll~' rtdllOtd to'; "If 70 Ind
_~,.!~n 7t~ 1II "" -~.'-' ~ ?to
lallO Amounl (tHmbtt Only) .
AdclllIOnal Amount'INDIVIDUAL COYEUtI
IINI'tCIAI\V - Alii ON 'ill
w. C>tI\lfy lIItl wllJIt W. ." paid \hi prttnlIMM lor \hi Qroup PoIloy ulhty btCOmt dUl, IIltInturtd Mtmbe, (called
"you" (11 "rour" U/ldIr \Ill. Ctrtlflc.lt) IIIn01udtlt lor 00VIf1gl tulljtct to \hi lttmt of lilt Otoup ~,
De'INITIONa. AI uttd ltIlhl. O.I1IIloaI,. \/It.. WOldt /live 1M ~ mtl/lll!g'
IDe"'''''''"'''''''''' mtmbtt 01 lilt Pl/ljelpa\lllO ....to(411JO/l whO II 0'1" IIII'd ~ 10 ~ of..
IlItlblt oe,.1ldtN "'"'" 'I04JI1I()CMI who" urvW 10 YtII' of. Md rour WlII\ItfiN ~ c:NIdflll Ufl6tr
" Y'"' 01. II alto "'"'" rour \,lII/ftMrltd cMdrlll bttw"" I' ftIId Z. yM/' vi", who ."IuIHlmt...,..1IId
wtoO "' ~ (iA y9l.l1Of .. ..... ~ vi "'" ~ and ~
Inlfy 0.... ""ant 1M .... (iA llihl(tI 1M 11ItI.I!w-t ,..,. ~
f Ll ;n;' (",.11l I\.il... M
"_"i;.I"'~I"'"
~
.
lnaurencl Plrlod '"'11II thl thl..-month period btglMing on IKh of thl Entry Dlt.. ..lac:ttd by the PIItlQ/pIlInQ
"'lOClltlon.
Hoaphll m.ln. I lawfully run InlUtul10n lot thl car. IIld tr'II/IItfl1 01 alclI or Inlurad JllIrlO/lll/lldlllhl dII""lon Ilf
I .tllt 01 Phyelclan.. h mUlt havI organ/,ad llOItttllllof mtdlCal dllgllOlll, t"ltmenland .urgtry. II mutt hlveR. hour
nUlling ..rvlcI.. II dot. not mlln In InltR1Il1On primarily orgllli,ad to t"I' thl aged, drug addIctt or aloohoIlCt It
dOl. nol ma.n I nUfllng homt, conVllelOl/lt horn. or I timttlt In.UtutlOn.
In-PIUlnt mnn. I JllIrllOllldmlltad to . hotPIlal I' . "ll4Intlled pltlellt and lot who.. conl\nerlllnltllt hoIpltal
ehalge. lIa IlOular and cUltomary dany chltge tolloom IIld bOard.
Inaurad PlllOn meana both you Ind 1'01I' Inaulad DeJlllndenll, II any.
Injury mtlna bodily Injury clulld by III lce~nt occurriII\J whllt 111I OIOUP Polley .1 In Iofce 1110 tIlIlnwltd P,rton
Ind le,ulling directly and Ind'JllIndenlly 01 In olhll elu.., In 10.. oovltld by lilt Oroup Policy.
Lo.. me In. Injury whiCh reaulll In loll 01 NI, or boddy injury O'lIIlnlllrld PlflOll and oceurl wllllt IN arpup PolICy
II In loree. Lou wllh "',,,nc. 10 hind Of hindi, I\xIt or I..t. mellll Mvlfance I' or lbov' thl wtIIl or IIIklt IOilll
(For South Cllolln. ",ldenl', 10.. 01 hand or hInd. lleo '"'11I1 10M of foul ftngarl 1 LON willi III"""" 10 ,ye Of
eye. m'lII' Iotal Ind Irrevocable 10.. 01 IhI InU" tlOhl of till .yl or IY", LotI 01 IpfIICn Of helrlng m'III1 IQlaI
and Irr,vocabl.1oat 01 IPH'h or h.lrll\Q Loll wllh rlllflnet to \Ilumb and lnelIa flngel ,",1II11OI1I1oIt 01 lhe \IIumb
IIId Inde. fingar on Ihe 11III1 hand
P,rtod 01 Hoaphll Conflnlm.nt ma.nl ,ach ..parlle durlllOf1 8UQC411tIM parlodl of hoIpllal (lOflfInIInarIl dullo
IhI aam. or rellltd CIU.., unit.. I.pataltd by eo day., wH11lI ~ad .. 0f\I period 01 hOIpiIal confiMmtnt
Prlnclpll lum maana IhI Additional Amount 01 InlurlllCl whic~ )'OIl tlarMd ill your Imoflm'nI fOffll
DINCfITl. While Ihlt OIOIlP Pl1llOY II In .ffect. Inlurad P"eonl It. OOV"ad ,. Iloutl I day, - daY'1 y,,, fOIlII"
,ccldtnllln IhI rou,.. 01 bullne.. 01 pI'laure eov". ~I (but it not llmitId 101 ~ ..liar on or 0"
Ihe Job. occurring In IhI horn', lrav,llng .. I pI'lIIIQIr by Iflln. aifplltlt. 1\IIOmCIOIII "" 0ltlIr publlo "" pnv."
lranaportllion. 1hl bln,lIt, provided under 11II Oroup "oI~ If, Plylblt In IddI1IOn to 'II~ 0111II lntut"'" ~ m.~
tit In ,NIK1 at 11II 11m. 01 ,lit ICCldIIIl
/I an In,urtd PellQ/l lu.laln, lloat wilhln _ dlyl Inlf IN dllt of III _1Hnt. W, will pay In Of\IIUfII,IN ~lIed
pereenl. 01 IhI P,lnclplllum ,1tctId Iof:
IAIIC AOOITIOHAL AMOUHT
.MOUHT' PIII\IIr "'"
LOll 0' lntvrt4 M.., MIiIIH ........, lntvr14 ''''' oa,.n.,"',
111ft CNIi
lII' t ClO't I ClO't ~ "'"
Both Handa or bOth ,... I ClO't I ClO't ~ ~
flight 01 bOIlI I Yft 1 ClO't I~ ~ ~
Ont tiand I ONI 'oot I~ I ClO't ~ IO"t
Ont tllll4 I tlgf'II 01 OM lye I ClO't I~ ~ ~
One '00I111gN of OM Iy. I~ I~ ~ W'lI
Ont tllII4 or ONI ,'* 01
Wtl of ONIly, I~ ~ ,... I~
~nor'~ l~ ~ U~ I~
1I11,1mO , 1Mf. 'ifill" (14
..,....h~ 100'/J Wit t~ ...
(lnly \><It......... ~ lif1)e,,1Q .t.4~ .....l/tt;,;Il4 "l)I~ It ;ttf"'''' If ..,.._. ....'.."lfr" ~.,..
~fldlt'"
10 HHi .""<)~~t ,t{"Jf*,.""n. r'" es.t,' A_,~~n,.-~f l\f'rY'c,Mlt t~.'" ~'~-Ufllh' ~:.. "f tJL. "'.~,."fI~ .'~'"",~f!+:"', ......,..
; . "",.,"
IXCLUIIONI. WI ",III 1101 Illy I b4lNhll(>l Iny 10M 10 lII'nwled ".,eon UUHd by Of IttIIIIInO "om:
I. IUl(;tda ",Mil UIII (II 1II1ll1\1l. (II
1. 1II1lnllonllly ..1I'n"~td InjUIY. (II
:I. _llIed Of unQatlaIed WII 01 Illy IlCIlheteol, Ot
.. aU lllvoI .. I plk:ll 01 "'I'll /IIfIlIbtI. Of
II Ilj')IIIIInO I moI(11 Vlhl(,lt whlllllllOot4;llld. 01
.. ,klilIQ (lI lltlVlli{/ III Illy kind 01 I~ It I Jlfol.lflQnll. 01
1 00If111l1111111J l)/ InllmptlllillO toIIUllIl I ltlony. Of
I voluntary UIII 01 lilY clIug. ~. (II It4IIIVI. ..~ It Pf.wlNd by . pII~.
DCP.ND'H' CHILO"'H II HI,., , II you IIIvI tlt<ittd lilt ,~ I'Ian " 10M rovt Ifft in III llOCld'nI, .,. wtlI PlY
. '.000 to youl b4lnlnc.lat'f, lot I~h c.NId ",110 .. III ,",U/Id ~I on lht CltIt of lilt 1GOidtnt, TIlII '*'-fIt II
In Idlllt~tfl to III VI"t/ b4l/lllht, ptylblt lot 10M 01 1111 01 1II1n1llf1d MllfIIOtt llndtf tIIit OtOllfJ fIlotIfy.
GOLDeH AOI ""Of.CTIOH. " you (II VOlIf In,uled IpQI.lII Inlllllll' 70. cover. NY oontInuI II tong II 1M
Jl/lnullflI " Jl.~j, Ind foQIh lllto !SUlCI Amwnt I/IClIM Pnnotjlll turn wlU be 'Id~ It 1oIIowt:
1 uJlon Inllll/ll"'l 01 '01 10, llle 1/IlOUfl' 01 InIUlII\UII, leduced by ~; tnd
it UlJOn IlIliI,"'lld 01 'ga 111 and l/\tll,h", \Nt """un' III IIIIU'ilIIC4l 'lft!'llllllnO II IIutIMw ,1duCltld by 71~.
HO'P"AL CAI" "H'flf, "lfIjUIY "UII,III InlU/1d "t/t(lIIto l4 oonllllld 1tl11lotp1111ltllllfl.palllnt within
IJI\Il y..' ul ttlll d... (ll tlllIlW(;tdanI, W. will pay . "nehl 01 '" oIlht Inlllfld Perto/l'l ,~ Ium lot _" lull
"I(tfllll (l' wnhn.mllfll, up 10 . m..ImU/II "",hI 01 ., ,ooo~, I!IOI\lh ThI 1iOII1IntmtrII",,* \It lOt I 1*100 01 motl
Ihln , d'" !tto,"ht, WIU till ulelllll4Nf 1t0000ltlt tift' city of Cl\lftflnttntl'l. tnd will ~ lot It tong II ,ht ,",\lIed
,..'- II to Wr\/IIIad, liUllot not "iOf.llltn " IIIOfIlll, ltIany llIIt PfttlOd of 001I""'''''''' 'OIl fHIt1ll1 month. ucll
lllllly loi".II1 wilt lit I(luallO I~ 01 IhI tn()IIlhly '*'e'"
IH'L. nOH OUAlID. II ~ _lid an ~1(lII1l AmoiInt of IIIIU1Woe IPrlMlPlllum). rw will be ~ed ~ ltIt
lhlllliUl'l Ouard btlllfll hl/'f two Y"ft. Ofll/lf lMlV.,wy ifili of )'OUt ~. ,our ~ M\WIlI of ed<IId
(.(;y~. will '" '\IloolIohf.lll; IfiUNIId'" ft;lt bentllt WIll ~ to 1nOI.... ~ POVtf. U IIlnG U VW IIIII\IiII
1fI...,'" \IhIH;t 1M Ilf."", 01 1111111 '/'WI (oOVtlf1Ot Nt bHII ~HNd . full ,.~ Attt ~ In '''''''''* IlII\'l Of
/>WI tyr.I will bllgtII . "" PfttIOO. .. ,Ilt'" 10 \hit MMIlt JiluvlIIOfl
"Him PA YMIHT'. lhllll/ltllt killCiM oiNt. lit" ~ JIIld IIIlMWtQl/lCil wlIll1/lt NntftciIllIY ~ and ltIt
l'/(NlINlRl' 14IQlIIlltllV tvGlI ~ylfltl'll ~ llIIy l4 III .1It(;1 tll/lf """ of JIIylllllll All WI4II t.w1lM .. ... Ptl410 VW
NHl'lClAltY.llhlN l'W'" VI" _1", ~ INlntArwt \IfIdIot 1M Q#q ~ ll.Ir lNIItWll ~)'''''Illf I(lH of lilt
t on VO\I' '-"" woll bt y{.lUI ~, If livInG. 0Ih4ltw1lt ywt .11....
~ pO ''''' dNlh of ywt II(lWU. will ... JOII. If lIvitIt, Pllillwtllf "" .tI... .1 )'OUI ~.
) pO ''''' 0.1111 of ywt IAwld ~Nldfan wlIl ... yO\!, If Nv/fiQ, ~ ywt tPWIt. II fMfit. ~ l/If ....,.
(II Y(lUI IA'\II" './OlIdIan
~
!
CHAHQI 0' .....'tCl."., YlIij .....t.1I'tt 'lfM, wIIIltIlht QI~ I".y II ItI lotH. III ~ ywI ~ Wll/'twl
w.I''''ftl '" 'hl! ...,..~, t., WlotW! Itq;It" (jI/ll/lf _1ft _ IN, filIfJl'ON IvII'tlIM '" Ua 'tit ~II.,. ...... tffIlc.1
..,.,.INlM.... on ,wIltollltl(luli ~fl(,'''1l OIIItl(lfflt 0/hH ~ Mil tndC!ItIffitfIl, 1111 ~ WlIII..... *"
I<'lIhd ,... '''~l .. (II ,,,. "'140 VW ~ lM ,~ .fttI~ (if ,... tw "'1Mn9 .. IN lltftt W. 1M.,.. IN '.....
AI., 111I....... foI ''''''9'' IA w,..fKiIII, WIll ,... tlfertt tIf. "'t'~ ~ It)' VI lit,.,. W. tMtII..lf Vl'NI '......
"UN CHAIfQt V~ mlt ~ ,...,.. ~ 1/lt ~ I".V It 1/1 /W... W ~'""" . ,...,""tHtMtl ""'''' I/l4
''''''''ltIJl'ij ~ ".111 "'...,lfoH on lNiI ""' MIfl WIll..... .1ltGt"" IN ,..II/IIr)' CMIt..".. OwII/jC~ '" tt.I<<I
r_lo/lt'",fNf/"fjl/ft;
'ltl'lMfHAflOH"" fHWAA~', ffWt 1MUf~ Wff,.,,,,,,,.,,,,..... ~ of..... "'11W1f"'"
, IN, I~' ". Q1W(1 ,."." ..,~, " i
it "...,~ fA ".. ~~ 'tIVIfItH ~,,~ ... .... " ~ ... '" f;I/1 ,.. ftfllM_ "'fIIlMl!9. ""
I IN; w~ "" ".. ~.,.. ~ t/I.ifififJ ~ JW If. Iit# ~ . JIII_flI t# IJItot '.,IM J"" AHl,'A1i11~, f!f
. 1#.ti~"",WI__.
. ".,
lneulance 011 each Inlured Oependtnl will I"mln.la 011 lhe aart... olllle foIIowtng 41...:
I. when row InturlllC4l "rmln.I..; Of
2. lhe and oIlhe InlurlllC4l Pariod Ih.I dlptndanl la no Ionotr an EllgIbla Otptndantj Of
3. lhe and ollhl InluIIllC4l P"1od lor which pramlum flu bHn paid, II you IalIIO pay IhI nMtwtd pramlum lor lha'
Inlured Dependant.
T Irmlnalion 01 ~r In.urlllC4l will be wllhoul pr.judklllo any belll"1 paylblt lor l01I wIIloh occurrld prior 10 'ermlnalion.
MINI T AliMENT, IIthll Ct!111lca1.,.rmlnal" becaUlt olllOflilllymtlll 01 prtmlum whtn " II duI. " ""y be rtlnal.led
wilhln 30 d.ywlrom IhI dill 01 luch '"mlnlUon by paymanl 01 all overdue pramlumt and aVldlnot ollnlurablllty
"Ulfeclory '0 U., il W. rlqulr. II.
HOW TO 'ILII A CLAIM, You mUll wrlll UI abou' a claim wllhln 20 d'YI a"" ,he occurr.nce 01 any Ioal or la 1\)01\
I' you 'an. W. will provldt you wllh claim lorml or W. Will ..nd lham '0 you wlINn III 41)'1 ."" you '.11 UI abOul
tha cl.lm II W. don'IMnd the 100ml In II d'YI, you cln limply..nd UI wrjll.n prool ol'ha lOll. The prool mUll
lhow 1M dall, lha chlrtel" .nd .':.n' olllll loaI.
You mUlt IInd proollo UI wllhln DO d.yl .1I1f th. dal. 01 luch 10.. II you ""not III1d prool'o UI wllhln DO dIYI,
you mUll do 10 II toon II you can. Unl.1I you hlv. bHn 1Ig.lly jneaplbI. olllllng IhI plool ollolt. W. wOII'1 ace'ill
"1111 " hlld a"" Of\t YWIf Irom Ih. Ii"" II Illould haVl bHn flied. You llan', alall any legal .cllon agalnl' UI unlll
eo d.yw all" you ..nd UI prool 011011 and you can', Ilart Iny Itgalectlon Igalnal UI mort 'han 3 yaarl (0 YI.fI
lor South Carolina I..ldtn") ."" you h.v. Mn'lh. plool.
MIUT A TlMIINT 01' AGI, " you mllltl'ed your age, all lmoun'. paylblt undIf lilt Group Polley will be tuch at
thl prlmlum p.1d would hlv. purchaMd II your corrtel '11I.
IT A TlMENTI Ol"NIURAIILlTY, ThI OrOllfl Policy. ,he AppliCation lor 'hi OlOUP PoIlOy IlI1d lilt Mtmbtr'. Enrollmtnl
form ar. the compltt. oontraC1 olln.uranct. All ...Ia""nll madt by you ar. contldtrId 10 IIIv. bHn mldt 10 IIlI
bNI 01 your know\adglllll1d bellll. No "I,.mtnl "" be uttd to void IhlllnlUfIllOll or deny a oIalm unItIe It..,.t~
II .igned by you. A11lr 2 Ylar,'lom thl.lfact"" dal. ollnwllflCI 011 any In.ured ""ton. no .lIt.m",' fNdt by you
"" be ulld to VOid Ihll lnlurance or deny. claim.
"HV.leAL IlCAMINA TIONI AND AUTO"IV. W., II Our own "pen.., h.ve"" f10ht 10 a.l/llln..n Inwrtd P.,1OIl
II o".n II I. r.lIOII.bly rlqUlred whllt a cl.lm II pending and '0 make .n 'l/IopIy In e... 01 dt.lh whet. II I. not
lortlIddlln by Ilw
CON'ORMITY WITH ITATI 'TATUn., Any ptI1 (II"" Oroup PoIlcy wNch, 0II1/lI1"-ctIVI 0... oIlht OIOUP Policy,
oonlllClI wllh Ih. .Ialul.. oIlht 1'11. wllllllht OrCIUP "Olley Wit dallv.rld It oNngId I" oonlormlo IhI /lIlnimum
llandl/dl ol'hoM II.lut..>
Thla C."lllctl. Itp/ec.. and .UPlllldtl .ny OIItlIlCII. Pf.vlOutly ItIutd 10 yolI.
~I.~
MIIIfNff /IIIOItflWl
,
....__'-_,....l
^~..-"....
. j. '
_ _~ '\.hiv....\o.a,~
1_ - -.- ...-' ' ,;i...',.
'" ,'~.I :. .~rlf~
t: 1. . , ' a f ,. \1 '
o I. .1, ~~ I~ ~
u... I. ;... .~ I · "
"i ~ .l'-~ ..,. ,.
~ :: "~)I '~M' !li'l ~II:
._" '.'~ ' r 1ft I It ~
~~.. ,"~; (5: .", ~':: "ll~!C ';I' !
,,' J ..: .... ~ . t ' I'", ii 2 '" ( . I .-
.' . , L c: . < . ~~ · · i ..
. ~] ~ ,:~! I H I ~ I ~I t! I.~: :
t ~ ~ ~ ,riP, II mt ill ~
: j f ~ ~; .It H'" \. I L j ~ ~ ) . ~ ' ~I
I ~ So' I .. JoI l
f" l~! 'E ." I' I II ~
~i ,;-: . ~ ,: , i' I: I' ·
'I ~. l't I. c.D (I, I. ,'.- \
"'t <",,' '" :." :'
,q I 31
r.~ ;~: ' C: - I .: l' I a II ' ~: ' ~ I
I'.' "'. ::l, " \:, ': .". . II ~' /
1,1 I' .'t::. '.' ,'r. I ,~ . j W'
'f
, ' ' . ,;' .. I if r I .'''' ·
kl:~ t: ,~ ',;..... L: !J~ . :~:~ II; ~ I IV.';'
" ".' '" ,.; " , c. ,1\ ., ;' I
\ tf "" l.d.1t I ~ I :
" a.J ".'. ..
. '~.;" 1t ',1 _. ';' ,1' ;.1' Iii t t
. .j ~ I.... ". '~. : j, ~ ...
~~S~ ;z :i~.:> ~11'1~ ~~;
:~:hnl ~ : '>'.ii tll!) i. ~;~
It t.li'~i'l 0 ~ ~':.:, I h. ~j\;~I.t ~ · ~ i }\::
H_ \ I' D.. It':'" \' .: ..: 9 ", ~ ~
tf~~,h~': ~f .~l\.EtlGt~I:;~ t..l.!,..:'
. .J:.. 0 -'" ,~ '
, ,'", ,. ;,; J' ... N M ',: J' }"I
"'..... . ... '
. ..... ~
.
- -.. -
.. *--
, -, ,.~..",
-'~., .-.
~ .. '';'" . "'l"'.'~! '.
'~
:, ...... ... .", .. .. ... ... .,.,1
.iIIiiiio...-.' .
Q."~.J~"L or ,"Y-llZl
I h.r.by o.rtlfY that I have ..rv.a . true .nd oorr.ot oopy
of \h. ror..oint 'Anav.r with ".v Matt.r. by Unlt.d .tat.. rir.t-
ell.' ..ii, po.t". pr.-p,id, on thl. date .ddr....d ,. follow.1
John N. .roujol, I.quir.
.roujo., Gilroy . HOUlton, p.e.
. North K,nov.r .tr..t
carl1.1.,'A 1101)
Of C....M.l '0 CUJlA Mutual
1M"''',," 01''''''
DaUdI Mirth U, 1'"
JU. I~
IZ 11 "n '95
;I,.q
{:; Ld i ,_I,' itf"'~ '!_''''
.;';:u~,L -': Hdl ;( t. ~;1(1'
i f "'~j J? ,,' ".J f X- -
ClRTl'ICATI 0' .IRVIC'
The Und.r.1,ntd h.r.by o.rtltl.. that on th1. date th.
tor.,olnv 'ra.olpe tor Intrv ot Appaarano. va. I.rv.d by tlr.t
ala., ..II. poat.,. pr.pald, upon the tOllowl""
John H. 'roujo., I.qulr.
'AOUJO', 01~Y , "OUlTON, ,.e,
4 North Manov.r .tr..t
C.rll.II,'A 11011
oa,", ,.a.u.rr(., 1...
v.
I IN nlE fOURT OF COMMON natAl OF
I ClIMIIERIANP COIJNTV, PENNSVLVANIA
I
I POCKt:f NO. 9S.Z09 Owll1.nn
I
I
I
I ('IVII. UIVISION . lAW
JOAN'" AlJtXANPER
PI.ndIJ
{'UNA MU11JAL IN8\1RANCIt
(;tWUP
u.r,ndlnl
AMENUt:O {'()I\tI'IAINT
,-'.----
Joan L. Aluand.r thloullh h., IlIorntyllloujol, Olho)' " lloullolI ..II I'onh th. followlnl
am.nd.d complllnl
I. Pllinll" i. Joan L. AI,lIand.r, 1110 known .. Joan L. S.muII. an adulllndivldual
".Idtnll al :lZJ IZth 511ftl. N.w Cumb.rland, Cumbtlland COUllI)'. Ptnnsylvanl. 17070. who
rllum.d her mald.n name aft.r d..lh of hft hu.band
l I).r.ndanl i. CUNA Muluallnlulan" OIIlUP. I Nlplllllion h.vinll . principal plica of
bUlln... all'O DOli 01. Wawtlly. lowI '0077o()06l; op.ralinll an" dol nil bUlln.., In Ih.
('ommo"\\..lth of P,nntylvanil
) Oeol'" D '.mull d.cflttd on O.nmber '. 1991
.. Otolll' O. S.muII hid ","tracl... with D.fllldlllllhloUllh hi. .mploy" \1P.I, at
W./ I I!III ""k Dllv.. lIarll.buIII. Oluphln ('OUIIly. ".nlll)'lvanl. ror . lif, In.uranc. poli~,
II HI forth in (',nll1ea" No 00066'''' lItuur ('Onlfacl No (l.J7.02U,'J. <<Jp)' of which J.
I1tachtd lIff,to II ~ull)jl A
~ Olin,. D '.muta dttlpl1'" 1'II1IIIlff AI th. btMfimr" ""lit, &ht pol""
,. llI, pllhfY ""1 . mutlll\ aceldllllal .em MlIIIl~.mbtun,"' f(ll\lli\1
, V.flt)- Ihll ch, Iltttnltll" In ch. tot'lOln. pl.". 1/' &rUIN corr"I I un4tf.11114 thll
tal.. .111I11I11I1' h.ffm "' IIIIdt tulIj4KI 10 th. ptnaIUtI or 'I pae. 4904 ftlllilll 10 IIIItWOrtl
,.ltlnulion 10 IIltho,lIi..
i-A
~~,
.,.,"".J
JOAN l. AU:XANUt:1t
l'Ia1nllrr
IN 'I1It: COlJln OF CO!\l!\lON l'I.IiAS OF
(1JI\IUERIANU COlINTV. I't:NNS\'I.VANIA
POCKET NO. 9!l.209 U~II or.""
v.
CUNA MlJl1.JAL INSURANCIt
GROUP
Ptf,ndlnl
CIVIL PIVISION . lAW
PIAINTI.'" REPI.\' TO DlFt:NDAN11i Nt."W MAlTER
U. No '''pon.lv. pltadin, i. rtqui"d
14. D.nl.d. On Ih. conuary, PlainlifT hll .111.d I claim upon which ttll.r mlY b.
,ranl.d. in Ihlllh. CIU.. o( d.lth WII carbon monollid. lnlOlIiellion; th. d.c.utd OlOr,. D.
S.muII WI' deni.d acc... 10 hi. hou.. IIId WII round In hi. vehicl. In hi. ,arl" In th. cold
o( th. win I"; and Ih. cumplainl IV'" th.llh. mann" of d.lth i. accidllllal.
15. Denlad. On th. cunlrary. PlainlifT il enlill.d 10 b.n.n..ln th.llh. polley of hi.
.mplo)'" UPS, b)' whom h. WII .mplo)'ad II lb. lim.. provld.. (or bIn.nl. whIR th. In.urad
.Illllbl. m.mb" .ulllinl bodil)' injury caulld by an accld.nl occurln, wh.n lb. policy I. In
roru, IN.. i. d.nnad II an injury ".ullln61 in lOll or Iir.. Plainl!fT av". lblllb. d..lb o(
dactdllll OlOrl\' D, ..muII WII ac,idtnlal ill lbal h. WII d.nlad acc... 10 hll hollt.. In
DK.mbtr. 199); lb. w.alb" WII cold. h. IIII.rtd th. lulomobil. 10 .Hp warm; h.
appI"nlly lumad on lb. tn,ln.; Ih. ,II beeam. "hIU.ltd, and h. wu IIph)'llllltd by carbon
monollld. inlOlIlcalion PJainUI'( il lb,,,rott ,"Iillad to b.n.nl. undtr lb. Policy and
C.JtlnUI., 1!1Ihibll' A and It of D.rtndMlI'. an.w" b,;n, IlIcorpor.l.d inlO PJailllift.
pl,Win,. by "("11I('
16. Admil!td lh..lbt deat.h. c.rlin,... *W. lbtllh. mtMIl 01 deat.h could 0.0. bt
.
d.'.,lIIln.d /low.v.r, d.nitd III., ,h. d..III ~""n"It t'".men' .. d.'.rmin.u~, .1 III
wll''''tr or no',h. d..lil WII dll' III an Heidlll' lh. "llln"" Ie III"lIad to . d.ltrmin.ll(ln
II . m,"" of I.w wh"h" del'h WII an u~idtn,aI de.lil
11 Adlflllltd III.. btn.n,. ... p.yabl. \IIIdll III. rolley Md ('.rtinnlt wit... dtilh rtluhl
('11m an H"dIn.
II ()IIIIId III., III, d..III WII IlOI,h. ..,III,o( 1/1 Hell'III' On 'h. ",nlrll)'. III. d..rh
wit lil. r"III,of II' Heiden.. f.lCcurrln, \IIIdtr etrCII",tlanCtI II M1 flIrm III p....raph I'
abov.. whl'" rlllnU" h.. ,h. r'thllll prllv. II . trlalllpon III. rlK'l
III AdmlllH 11I.,11I... WII an a11'l\luon 'hit lil. b~d aI<<thol eonllll' or dH.UIIl
(110'11' P ..mll" W.. n PIIIIIllIII., In (H' III. aI~1 conI"" WII II .1I.,ed, &tItr
"'lI(Inabl. ."v..\i,I'Ion rlllnuff i. withou' bowllll.. "r inAtrmlllOl\ tllM.ltn'lO fntlll .
wll.( II to th. 'ruth o( the .v,,""", Ptnitd that thi, IOlItmultl IItW m,"" 1\. bloo4
aj,oh(ll ","IfII' II 01\1)' OIl. fKtor to lit CORlidtrt4 durin, tht trial or dill.... Ploo4 ai_I
'(lnI"" tkttt 110' pI"''''' rftOv~ by th. "1/"11" II I r..ul' "r tht ICcidenlll dtIlh.
20 Ad""lttd 'Iow.v... denied that III)' "r tilt .ulullClftl in tacl o"uulll.. . mIl1II of
ru' (lr II" On tilt COIIUIIy. dtadl Ofcwt4 II tilt r,",,' or II' Mcl4tn1. .. 1~"ft4 1ft
l'I..RUrr. plHdln,. Ptn.t4 dllllhl, plI.,,"" f(III,",lIttt W IV"""'" or IIIW IIlI1ttf
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,.1.. .111""tnl' h,,"n .,. madt .ultJIC' to Ill. "".hl" 0' II PaCt .~ It/llill' to IlIltworn
'alllncllion to IUlhollli"
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I IN nlE COVR'f OF COMMON '1.&A8 0'
I CUM8&RIAND COUN1'V, ,ENNSYLVANIA
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I DOCK" NO. .10209 a..1I Tlnn
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I CIVIL DIVISION. lAW
,X)AN I. AU'.XAND&R
PI...."
l'llNA MU1\IAL INSURANCI
OROU,
D.'........
ClRnFlCATJ: or IIRVICE
I. John lllttolll... Jill'"'" h"fby "11l/Y thlll havt ..rnd I IrUlllld conHI oopy or the
to..... "11111111', "'I~ 10 u.I'",dlllr. N.w Mill" upon Jam.. P. D.An"lo. or MeN....
Wall.... M4 Nurkk. attomt)' tot D.t"'danc. at 100 Pill. I"Ht.lll1rltblll" PA 17101.1\66.
by n,.. .,...IIIIiI. 1ft April --' 19ft
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I (VMllJU..\ND ('OUNn', 'INNIVLVANI4
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I DOCl(ff NO. ".10'1 "'II TIM
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I ('IVII. DIVISION. lAW
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CUNA M1I1\IAL &NIURANCI
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d1n'JQliJQ1l.AUJ)I~:WIt/t Of 6'.fWIQ8I
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I IN nllt COURT OF COMMON PLEAS or
I (.llMBERLAND COUNTV, PENN8YI.vANIA
I
I DOCKET NO. 911.209 0\'11 T.11II
I
I
I
I CIVil, DIVWION. LAW
JOAN I. ALEXANDER
Plllndrr
l1JNA MU'IlJAL INSVRAN(l:
(;ROUP
D.f.ndanl
CER11YICATE OYIIERVICE
I, lohn II. Drou,/o.. l!lQulr.. h.,.by "nil'y 111." h.v. ..rvad , Irut and ~rrlCI copy of 111.
("r'aoin, Amtndad Complainl upon Jam.. I'. D.Ana.lo. of MeN"., Wall,ee. and Nurlck,
'"omay fot D.ftndanl, .1 100 Pin. litH" IIlttitbur..1'A 1710'.1166, by nrll cllll mail, on
F.bruary ~7, 199',
..,.".'
OROUI08. OIl.ROY " 1I0USTON, '.C.
4 Nonh 1Il11Ov.r 51/"1
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I IN TII& COllin' ot' COMMON PUAS OF
I ClIMRKRl.AND (~OUNTV. PKNN8\'I.v AN1A
I
I I)OCkt:T NO. ".JlI9 C:h'lITtrm
I
I
I
I CIVil, IlIVllilON . tAW
JUAN I.. AU"ANIUCR
l'lalnll"
C:UNA MUTUAl. INSURANCE
Wtolll'
I)tf.ndan'
I'RAICII't: TO IA1'IIFV
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1'0 TIll! PROT1I0NOT^"V:
PI,... mark tlw "v, e... ...I.ntd.
April II, 1996
"2
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tIROUJOJ. OILKOY A 1l0U$TON. ',t:,
. Nonh ll~" IItttl
('ifill", "fW~lvlllil 1101l
711ta4J,..m4 117116601690
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