Travel Accident Insurance Certificate Template - Free Download
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Travel Accident Insurance Certificate Template
Travel Accident Insurance Certificate Template
Having Issued Group Travel Accident Insurance Policy No. GA 1008-12 (formerly Group Travel Accident Insurance Policy No. 1007-08) to
BRITISH COLUMBIA AUTOMOBILE ASSOCIATION
Head Office – 4567 Canada Way, Burnaby, British Columbia V5G 4T1
for optional purchase by its Members, certifies that it will pay the optional benefits described herein for accidental death, dismemberment, paraplegia, quadriplegia, loss of speech,
loss of sight, or loss of hearing, resulting from Airline Injury, Automobile Injury, Common Carrier Injury, Pedestrian Injury, Terrorism Injury or Watercraft Injury, subject to the provisions
of the Group Travel Accident Insurance Policy and this Certificate.
THIS CERTIFICATE ANNULS ANY PRIOR ISSUED CERTIFICATE.
The Insurer agrees to pay the Insured Member, or on behalf of the Insured Member, for the period beginning with the effective date of this Certificate as shown above at 12:01 am
Standard Time at the place where the Insured Member resides, for accidental death, dismemberment, paraplegia, quadriplegia, loss of speech, loss of sight, or loss of hearing,
resulting from Airline Injury, Automobile Injury, Common Carrier Injury, Pedestrian Injury, Terrorism Injury or Watercraft Injury, subject to the provisions of the Group Travel
Accident Insurance Policy and this Certificate.
If “such injuries” to the Insured Member shall result within 90 days from the date of accident, the Insurer will pay the amount shown opposite such loss to which the Insured
Member is entitled, but only one of the amounts so specified (the greater) shall be paid for “such injuries” resulting from one accident.
Schedule of Principal Benefits Schedule of Insured Benefits
Indemnity for loss of life of the Insured Member will be payable in accordance with the beneficiary designation on record with the Association and effective at the time of payment. If
no such designation is then effective, such indemnity shall be payable to the estate of the Insured Member. All other indemnities herein are payable to the Insured Member. Subject to
any applicable statutory restriction, the Insured Member may change the beneficiary from time to time by written notice in a form satisfactory to the Insurer. The right to change the
beneficiary is reserved to the Insured Member, and the consent of the beneficiary or beneficiaries, if any, shall not be requisite to any change of beneficiary or beneficiaries.
TRAVEL ACCIDENT INSURANCE CERTIFICATE
MEMBER NO. NAMES OF INSUREDS PLAN EFFECTIVE DATE EXPIRY DATE
BCAA Insurance Corporation
Head Office – 4567 Canada Way, Burnaby, British Columbia V5G 4T1
PART 1 – INSURING AGREEMENT
PART 2 – SCHEDULE OF BENEFITS
TRAVEL ACCIDENT INSURANCE
B
ENEFICIARY DESIGNATION FORM
Please complete and return this form only if you need to designate or update the beneficiary for your Travel Accident Insurance coverage.
D
esignated Beneficiary
Member’s Signature: ________________________________________ Date: _____________________
Need more coverage See reverse for upgrade options.
THIS FORM MUST BE SIGNED
Underwritten by BCAA Insurance Corporation
Name (First and Last) Address Relationship %
1
2
PART 3 – BENEFICIARY
Member Name: ______________________________
Member No:
620-273- __ __ __ __ __ __ __ - __ __ __
Plan
Automobile Injury
P
edestrian Injury
T
errorism Injury
W
atercraft Injury
Common
Carrier Injury
Airline Injury
Platinum
$75,000 $225,000
M
$75,000 $75,000
Diamond
$50,000 $150,000
F
$50,000 $50,000
Gold
$25,000 $75,000
E
$25,000 $25,000
Silver
$15,000 $45,000
C
$15,000 $15,000
Bronze
$10,000 $30,000
B
$10,000 $10,000
A
$5,000 $5,000
Type of Loss
% of
Principal
Benefit
Loss of life
100%
Loss of two members (hand, foot or eye)
100%
Loss of speech
100%
Loss of sight in both eyes
100%
Loss of hearing in both ears
100%
Paraplegia or Quadriplegia
100%
Loss of one hand or one foot
50%
Loss of one arm or one leg
75%
Loss of sight in one eye
75%
Loss of hearing in one ear
50%
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source: bcaa.com
Travel Accident Insurance Certificate Template
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