West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-12 - Individual Accident And Sickness Insurance Minimum Standards
Appendix G

[COMPANY NAME]

ACCIDENT-ONLY COVERAGE

OUTLINE OF COVERAGE

(1) Read Your Policy Carefully. -- This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance policy, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurer. It is, therefore, important that you Read Your Policy Carefully!

(2) Accident-Only Coverage. -- Policies of this category are designed to provide, to persons insured, coverage for certain losses resulting from a covered accident only, subject to any limitations, deductibles or copayment requirements set forth in the policy. Coverage is not provided for basic hospital, basic medical-surgical or major-medical expenses. [Note: Final sentence may be appropriately modified, if necessary, to reflect coverage provided.]

(3) [A brief specific description of the benefits contained in this policy.]

(4) [A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay or in any other manner operate to qualify payment of the benefits described in paragraph (3) above.]

(5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.]

NOTE: In the outline of coverage forms that follow, only the material appearing in brackets is to be composed by the insurer in language appropriate for the coverage provided. All other material shall appear in exactly the form set forth in this rule.