Fidelity and Deposit Company of Maryland

BALTIMORE, MD.

Commenced Business 1890

EDWIN WARFIELD, President.

ROBERT S. HART, Secretary.

The Fidelity and Deposit Company issues policy forms in its accident and health department with annual premiums per $5000 principal sum, Select, as follows: "Universal Accident," annual premium, $25; "Universal Disability," annual premium, $60; "Ordinary Accident," annual premium, $20; "General Sickness," annual premium, $35.

The "Universal Disability" policy calls for an increase in premium of $2 per $1000 when insured reaches age 51. The "General Sickness" policy requires an increase of $2 for each $5 weekly indemnity at age 50 and an additional $1 increase at age 55.

The "Ordinary” accident policy provides indemnities for death and disability or dismemberment for 200 weeks. The "General Sickness" contract provides weekly indemnities for confining illness not exceeding 26 weeks, and one-half weekly indemnity for non-confining illness not exceeding eight weeks. The company's liability in no event to exceed 26 weeks in any policy year.

POLICY FORM-"UNIVERSAL ACCIDENT."

PRINCIPAL SUM, $5000-$10,000.

WEEKLY INDEMNITY, $25.

ANNUAL PREMIUM, $25.

Fidelity and Deposit Company of Maryland, Home Office, Baltimore, Md. (herein called the company), in consideration of the agreements and statements in "The Copy of Application" set forth hereon, which statements the insured makes and warrants to be true by the acceptance of this policy, and which are made a part hereof, and of the annual premium of twenty-five dollars, does hereby insure, subject to all the provisions and conditions herein contained or endorsed hereon, Henry Stevens (herein called the insured) of Baltimore, Md., and whose occupation is accountant, for the period of twelve months, from twelve o'clock noon (Standard time) of the twentieth day of January, 1912, against disability or death, as herein defined, resulting directly, independently and exclusively of any and all other causes from bodily injury effected solely through accidental means (suicide, or any attempt thereat, sane or insane, not included) as specified in the following Schedules:

PART I.-Principal sum, first year, five thousand ($5000) dollars; weekly accident indemnity, twenty-five ($25) dollars.

SCHEDULE OF INDEMNITIES

SINGLE INDEMNITY.-Death, dismemberment or loss of sight. If such bodily injury shall from the date of the accident, independently and exclusively of all other causes directly, continuously and totally disable and prevent the insured from performing any and every kind of duty pertaining to his occupation, and if, during the period of such continuous and total disability, and within two hundred weeks from date of accident, such bodily injury shall be the sole and direct cause of any one of the losses enumerated in this part, the company will pay the sum specified opposite such loss and in addition thereto an indemnity as specified in Part I for the period of such continuous and total,

disability between the date of the accident and the date of such loss. Or, if within ninety days from the date of the accident, irrespective of total disability, such bodily injury shall be the sole and direct cause of any one of the losses enumerated in this part, the company will pay the sum specified opposite such loss.

SPECIFIC INDEMNITIES.-For loss of life, or both hands by severance at or above the wrist, or both feet by severance at or above the ankle, or one hand and one foot by severance at or above the wrist or ankle, or entire sight of both eyes, if irrecoverably lost, or entire sight of one eye, if irrecoverably lost, and one foot by severance at or above the ankle, or entire sight of one eye, if irrecoverably lost, and one hand by severance at or above the wrist, the principal sum; either leg by severance at or above the knee, or either arm by severance at or above the elbow, three-fifths the principal sum; either hand by severance at or above the wrist, or either foot by severance at or above the ankle, or entire sight of one eye, if irrecoverably lost, one-half the principal sum. PART II. SINGLE INDEMNITY-TOTAL AND PARTIAL DISABILITY.

TOTAL LOSS OF TIME.-Or, if such injury shall not result in any of the losses enumerated in Part I, but shall directly, immediately, wholly and continuously disable and prevent the insured from attending to any and every kind of duty pertaining to his occupation, the company will pay him, while so disabled, the weekly indemnity as specified in Part I.

PARTIAL LOSS OF TIME.-Or, for a period, not exceeding twenty-six consecutive weeks, during which the insured shall, by reason of such injury, be immediately and continuously disabled and prevented from performing fully work essential to the duty or duties pertaining to his regular occupation, or for like disability not exceeding twenty-six weeks immediately following totally disability and not extending beyond the limit thereof the company will pay him one-half the weekly indemnity as specified in Part I.

PART III. DOUBLE INDEMNITY.-Or, if such bodily injury is sustained by means as aforesaid (1) while the insured is a passenger in or on a public conveyance (including the platform, steps or running board thereof) provided by a common carrier for passenger service, or, (2) while a passenger and within a passenger elevator (elevators in mines, excepted), or (3) if such injury is caused by the burning of a building while the insured is therein, or (4) if caused by a stroke of lightning, or (5) if caused by the collapse of the outer walls of a building while the insured is therein, then the amount to be paid shall be double the sum that would otherwise be payable as provided in Parts I or II or V or VII hereof.

PART IV. SPECIAL INDEMNITY.-Freezing, hydrophobia or asphyxiation caused solely by accidental means (suicide, or any attempt thereat, sane or insane, not included) shall be considered as covered by this policy. Blood-poisoning resulting directly from an accidental bodily injury shall be deemed to be included in the said term bodily injury, PART V. ACCUMULATIVE PROVISION.-Each consecutive full year's renewal of this policy, if the premium be paid annually in advance, will increase the respective sums specified in Part I by ten per cent.; if paid other than annually in advance, by five per cent., until in either case, according as premium may be paid, fifty per cent. is thus added to the original principal sum. Thereafter, so long as the policy is in force, the insurance will be for the said principal sum plus the accumulations. This provision shal! not apply to increase the weekly indemnity under this or any other section of the policy.

PART VI. WEEKLY INDEMNITY ACCUMULATIONS.-If the insured sustains a bodily injury and is totally disabled as set forth in paragraph I of Part II of this policy, and is so totally and continuously disabled for a period exceeding ten consecutive weeks, the weekly indemnity to which he may be entitled as specified in Part I of this policy will be increased as follows: Commencing with the eleventh week twenty per cent, and twenty per cent every ten weeks thereafter of continuous and total disability, until such increase has reached one hundred per cent, of the original weekly indemnity as specified in Part I; provided, that no claim is made under Part III of this policy and that no claim shall be in excess of the original principal sum unless the insured is entitled to a specific indemnity as provided in Part I of this policy.

PART VII. SURGICAL OPERATION FEES.-If a bodily injury, for which indemnity is payable under this policy, is suffered by the insured, and if on account of said bodily injury, and within ninety days from the date of the accident, the insured undergoes a surgical operation named in the "Schedule of Operations" set forth hereon, the company will pay the insured (in addition to the indemnity payable for said bodily injury) the sum set opposite such operation in said schedule; provided, that not more than one of the said amounts so named shall be payable for bodily injuries resulting from one accident.

PART VIII. OPTIONAL INDEMNITY.-If the insured shall sustain bodily injury received as set forth in this policy and named in the "Schedule of Injuries" endorsed hereon, he may elect, subject to all the terms and provisions hereof, to receive the amount of indemnity specified opposite such injury in lieu of all other indemnity for either total or partial disability, except as provided in Part VII, provided he shall signify his choice in writing, addressed to the company at Baltimore, within two weeks from the date of accident. No claim for more than one of the indemnities in said schedule, the result of any one accident, shall be valid.

PART IX. HOSPITAL INDEMNITY. If a bodily injury, for which indemnity is payable under this policy, is suffered by the insured, and if on account of said bodily injury, and within ninety days from the date of the accident, the insured is removed to a regularly incorporated hospital, the company, provided that no claim is made under Part VII, will pay the insured (in addition to the indemnity payable for said bodily injury) for the period, not exceeding ten weeks, during which the insured is necessarily confined in the said hospital, the amount expended by him weekly on account of the hospital charges, not exceeding one-half the weekly indemnity as specified in Part I.

PART X. MEDICAL ATTENDANCE INDEMNITY. Or, if such injury shall not result in either disability or death, but shall require immediate medical or surgical treatment by a physician or surgeon, the company will reimburse the insured for the cost thereof not to exceed the weekly indemnity as specified in Part I, provided the physician's or surgeon's receipt and affidavit on the company's blank is furnished the company within thirty days from the date of the accident.

PART IX. CERTIFICATE OF IDENTIFICATION AND REGISTRATION.-In consideration of the receipt at the home office of the premium for this policy, the Fidelity and Deposit Company of Maryland has placed the insured's name on the registration list. If the insured shall, by reason of injury during the time this policy is in force, be physically unable to communicate with friends, the company will, upon receipt of a telegram or other message giving this policy number, immediately transmit to the relatives or friends of the insured any information respecting him, and will defray all expenses necessary to put the insured in communication with, and in care of friends, not exceeding the sum of twenty dollars ($20) for each $1,000 of principal sum mentioned in this policy.

SCHEDULE OF INJURIES. (Optional Indemnities-see Part VIII.) The amounts stated in the following "Schedule of Injuries" are payable under this policy if issued for five thousand dollars principal sum, proportionate amounts being payable if the policy is issued for a larger or smaller principal sum: Ordinary accidents, Part I. For loss of one or more fingers (at least one entire phalanx), $150; one or more entire toes, $200. For complete hernia, caused solely and directly by accidental injury, $70. For complete dislocation, viz.: of the shoulder, $100; elbow, $100; wrist, $125; hip $300; knee, $150; any bones of foot, $150; ankle, $150; two or more toes, $50; two or more fingers, $50. For the complete fracture of bones, viz.: of the skull, both tables, $325; lower jaw, $75; clavicle (collar bone), $150; pelvis, $250; thigh, $300; leg, $200; patella (knee cap), $200; arm between elbow and shoulder, $300; forearm between the wrist and elbow, $150; two or more ribs, $100; foot, $125; hand, $125; two or more toes, $100; two or more fingers, $100. Travel, etc., accidents, Part III, double the above amounts.

GENERAL PROVISIONS

(1) This policy, with a copy of "The Application" therefor signed by the insured and any rider or endorsements bearing the signature of the president, a vice-president or the secretary of the company, and endorsed hereon, or attached hereto, constitutes the entire contract of insurance except as the same may be effected by any table of rates or classification of risks filed by the company with the insurance department of the state wherein this policy was issued, and effective at the time of such issuance or delivery.

(2) No statement made by the insured, not incorporated in or endorsed on this policy issued to the applicant, shall void the policy, or be used in evidence, and no provision of the charter, constitution or by-laws shall be used in defense of any claim under this policy unless such provision is incorporated in full in this policy; but this requirement shall not be deemed to apply to the table of rates or manual of classification of risks filed by this company with the state official having supervision of insurance companies in the state wherein this policy was issued prior to the date of the occurrence of the injury for which indemnity is claimed.

(3) If the insured is injured, fatally or otherwise, after having changed his occupation to one classified by the company as more hazardous than that herein stated, or while he is doing any act or thing pertaining to any occupation so classified (except ordinary duties about his residence or while engaged in recreation) the company's liability shall be only for such proportion of the principal sum or other indemnity under this policy as the premium paid by him would have purchased at the rates, but within the limits fixed by the company for such increased hazard, according to its rates and classification of risks filed, prior to the occurrence of the injury for which indemnity is claimed, with the state official having supervision of insurance companies in the state where the insured resides at the time this policy was issued.

(4) If a past due premium shall be accepted on this policy by the company or by branch office or by a duly authorized agent of the company in the city, town or county in which the insured shall reside, or by the duly authorized agent of the company who accepted the last premium on the policy, if so authorized at the time of the acceptance of the past due premium, such acceptance shall reinstate the policy in full as to disability resulting from accidental bodily injuries thereafter sustained."

(5) Written notice, with full particulars and the full name and address of the insured of an accident on account of which a claim may be made under this policy, must be given to the company at its home office in Baltimore, Maryland, or to one of its duly authorized agents in the city, town or county in which the insured shall reside at the time giving of such notice, within thirty days from the date of the accident, provided that in the event of accidental death immediate notice must be given, unless such notices as herein specified may be shown not to have been reasonably possible.

(6) Payment of any claim hereunder will be made immediately upon receipt at the home office of the company of due and satisfactory proofs of claím. No action-at-law or in equity shall be begun before sixty days nor after two years from the date when the final proof of claim is filed with the company.

(7) Proof of claim in writing must be furnished to the company at its home office, Baltimore, Maryland, in case of claim for loss of time within ninety days after the termination of the period of disability for which the company is liable, and in case of claims for loss of life, limb, limbs, or sight, within ninety days after the occurrence of such loss. (8) The company may cancel this policy at any time by written notice delivered to the insured or mailed to him at his last address as shown by the records of the company and the tender of the company's check for the unearned portion of the premium, but

such cancellation shall be without prejudice to any claim arising on account of disability commencing prior to the date on which cancellation takes effect.

(9) The company shall, in case of injury, disability or death, have the right and opportunity to examine the person of the insured when and as often as is required, and shall also have the right and opportunity to make an autopsy in case of death, where not forbidden by statute.

(10) The consent of the beneficiary shall not be requisite to a surrender, alteration or assignment of this policy, nor to a change of beneficiary.

(11) Indemnity for loss of life of the insured, or disability indemnity accrued and not paid the insured prior to death, shall be paid to the beneficiary, if surviving; otherwise, to the executors, administrators, or assigns, of the insured. Claims for disability indemnity of less than three months' duration shall be payable at termination of disability only; claims in excess thereof shall be payable at the end of each three months of continuous disability, due and satisfactory proofs, as aforesaid, being required before each payment.

(12) This policy covers accidental bodily injuries only when sustained by a male person over eighteen and under sixty-five years of age, and while not engaged in military or naval service in time of war, aviation or ballooning.

(13) Compliance with all of the terms and conditions of this policy shall be a condition precedent to the recovery of any claim hereunder. No agent has authority to alter this policy or to waive any of its conditions. Notice to or from any agent, or knowledge acquired by him shall not be held to effect a change or waiver of this policy, or any condition thereof. All death claims under this policy shall be subject to proof of insurable interest, and no assignment of, or change in this policy, or waiver of any of its conditions, shall be valid unless agreed to in writing by the president, vice-president, or secretary of the company and endorsed hereon.

In witness whereof, the Fidelity and Deposit Company of Maryland has caused this policy to be signed by its president and secretary, and countersigned by its duly authorized representative.

SCHEDULE OF OPERATIONS.-(Indemnity for surgical operations-see Part VII) The amounts stated in the following "Schedule of Operations" are payable under this policy if issued for five thousand dollars principal sum, proportionate amounts being payable if the policy is issued for a larger or smaller principal sum. Amputation of foot, hand or forearm, $25; leg or arm, $50; thigh, $100; finger or fingers, $10. Dislocations, reduction of shoulder, elbow, hip, knee or ankle, $25; wrist or lower jaw, $15; thumb or fingers (two or more), $10; Excision of shoulder, hip or knee joint, $100; elbow, wrist or ankle joint, $25; toe or toes, $25 Fractures, reductions, nose, lower jaw, collar bone or shoulder blade, $25; breast bone, $10; rib or ribs, $10; upper arm, $35; forearm (one or both bones), $25; wrist or hand, $15; fingers (two or more), $10; any of the bones of the pelvis or sacrum, $50; coccyx, $10; thigh, $75; knee cap or legbones (one or both), $50; bones of foot, $15; toe or toes, $10 Gunshot wounds-treatment not necessitating amputation or laparotomy, $25 Hernia (abdominal)-any cutting operation for the radical cure of the reducible, irreducible or strangulated form, $100 Hydrophobia-Pasteur treatment, $50 Laparotomy (opening of the abdominal cavity for an operation on any organ contained therein, or for traumatic peritonitis, or exploratory incision), $100 Necrosis (death of bone)-sequestrotomy (removal of dead bone), $35 Skull trephining for fracture or other cause, $100 Synovitis (inflammation of the lining membrane of joint), incision, $25 Lockjaw-injection of anti-tetanic serum into frontal lobe of brain, $100; into spinal canal, $50 Wounds of scalp or other parts. -suturing, $5

COPY OF APPLICATION endorsed on policy.

POLICY FORM-"UNIVERSAL DISABILITY"

PRINCIPAL SUM, $5000 $10,000. WEEKLY INDEMNITY, $25.

ANNUAL PREMIUM, $60.

This form is the same as the foregoing, with the health feature added, except where the phraseology conflicts with the health provisions and in the following clauses:

PART VII. OPTIONAL INDEMNITY.-If the insured shall sustain bodily injury received as set forth in this policy and named in the "Schedule of Injuries" endorsed hereon he may elect, subject to all the terms and provisions hereof, to receive the amount of indemnity specified opposite such injury in lieu of all other indemnity for either total or partial disability, except as provided in Part XIII, provided he shall signify his choice in writing, addressed to the company at Baltimore, within two weeks from the date of accident. No claim for more than one of the indemnities in said schedule, the result of any one accident, shall be valid.

PART VIII. See Part X preceding contract.
PART IX.-See Part XI preceding contract.

SCHEDULE OF INDEMNITIES-SICKNESS.

PART X. WEEKLY INDEMNITY-TOTAL DISABILITY.

HOUSE CONFINEMENT.-If any sickness contracted by the insured, during the term of this policy or any renewal hereof, and not hereinafter excepted, necessarily confines the insured in the house for a period beginning during the said term, and prevents the

insured throughout the period of such confinement from performing any and every kind of duty pertaining to his occupation, the company will pay the insured for the period of such confinement, not exceeding fifty-two consecutive weeks, the weekly indemnity as specified in Part I.

DISABILITY FOLLOWING HOUSE CONFINEMENT.-If the insured shall be confined in the house and disabled within the terms of the preceding paragraph, and if continuously thereafter the sickness causing the said confinement in the house totally disables and prevents the insured from performing any and every kind of duty pertaining to his occupation (but not necessarily to the extent of confining him in the house), the company will pay the insured for the period of said disability, if any, following said confinement in the house and within fifty-two weeks from the beginning of the said confinement, onehalf the weekly indemnity as specified in Part I.

PART XI. PARALYSIS FROM SICKNESS.-If any sickness contracted by the insured during and under the terms of this policy, and not hereinafter excepted, results during the said term in permanent paralysis whereby the insured during the said term irrecoverably loses the entire use of both hands, or both feet, or one hand and one foot, and if the insured on account of one of the said losses resulting from permanent paralysis(1) is permanently unable to engage in any work or occupation for wages or profit; and (2) survives, for the period of one year, one of the said losses resulting from permanent paralysis; and (3) at the end of the said period of one year is declared by medical authority satisfactory to the company to have irrecoverably lost entire use of both hands.or both feet, or one hand and one foot, and to be permanently unable to engage in any work or occupation for wages or profit by reason of one of the said losses resulting from permanent paralysis; the insured may elect to receive, in lieu of all other indemnity under this policy except surgeon's fee or hospital charges to which he may be entitled, one-half the original principal sum.

ACCIDENT OR SICKNESS INDEMNITY.

PART XII. HOSPITAL INDEMNITY.-If a bodily injury or sickness for which indemnity is payable under this policy, is suffered by the insured, and if on account of said bodily injury or sickness, and within ninety days from the date of the accident or inception of sickness, the insured is removed to a regularly incorporated hospital, the company, provided that no claim is made under Part XIII, will pay the insured (in addition to the indemnity payable for the said bodily injury or sickness) for the period, not exceeding ten weeks during which the insured is necessarily confined in the said hospital, the amount expended by him weekly on account of the hospital charges, not exceeding on half the weekly indemnity as specified in Part I.

PART XIII. SURGICAL OPERATION FEES.-If a bodily injury or a sickness, for which indemnity is payable under this policy, is suffered by the insured, and if on account of said bodily injury or sickness, and within ninety days from the date of the accident or inception of sickness, the insured undergoes a surgical operation named in the "Schedule of Operations" set forth hereon, the company will pay the insured (in addition to the indemnity payable for said bodily injury or sickness) the sum set opposite such operation in said schedule; provided that not more than one of the said amounts so named shall be payable for one sickness or for bodily injuries resulting from one accident.

SCHEDULE OF OPERATIONS.-(Indemnity for surgical operations-see Part XIII.) The amounts stated in the following "Schedule of Operations" are payable under this policy if issued for five thousand dollars principal sum, proportionate amounts being payable if the policy is issued for a larger or smaller principal sum: Abscess or boil (one or more)-incision, $5. Amputation of foot, hand or forearm, $25; leg or arm, $50; thigh, $100; finger or fingers, $10. Aneurism (tumor of artery)-ligation, $50. Appendicitis, $100. Bone abscess-trephining, $25. Bronchotomy, thyrotomy laryngotomy, laryngotracheotomy or tracheotomy, $50. Carbuncle (one or more)-incision and treatment, $25. Caries (bone ulcer) curetting, $15. Dislocations, reduction of shoulder, elbow, hip, knee or ankle, $25; wrist or lower jaw, $15; thumb or fingers (two or more), $10. Excision of shoulder, hip or knee joint, $100; elbow, wrist or ankle joint, $50; toe or toes, $25. Eye, ear nose or throat-any cutting operations, $10. Felonincision, $5. Fractures reduction of nose, lower jaw, collar bone or shoulder blade. $25; breast bone, $10; rib or ribs, $10; upper arm, $35; forearm (one or both bones). $25; wrist or hand $15; fingers (two or more), $10; any of the bones of the pelvis or sacrum, $50; coccyx, $10; thigh, $75; knee cap or leg bones (one or both), $50; bones of foot, $15; toe or toes, $10. Ganglion (cystic tumor of tendon sheath)-incision and curetting, $15. Gunshot wounds-treatment not necessitating amputation or laparotomy, $25. Hernia (abdominal)-any cutting operation for the radical cure of the reducible, irreducible or strangulated form, $100. Hydrocele-tapping-incision_or excision of sac, $25. Hydrophobia-Pasteur treatment, $50. Ingrowing toenailremoval, $10. Intestinal obstruction (see laparotomy). Kidney-fixation or removal, $100. Laparotomy (opening of the abdominal cavity for an operation on any organ contained therein, or for traumatic peritonitis, or exploratory incision), $100. Lithotomy (operation for removal of stone in bladder), any cutting, $100. Lockjaw-injection of anti-tetanic serum into trontal lobe of brain, $100; into spinal canal, $50 Mastoiditis operations for, $50. Necrosis (death of bone)-sequestrotomy (removal of dead bone), $35. Oesophogotomy for stricture or other cause, $100. Peritonitis (see laparotomy). Paracentesis-tapping of abdomen, $25; bladder, $25; ear drum, $15. Rectum operation for hemorrhoids (external or internal) excision or ligation, $25; prolapsed-operation for, $25; fistula in ano-incision, $25; polypus extirpation $25; malignant stricture-excision or colostomy, $100. Skull trephining for fracture or other cause, $100. Synovitis (inflammation of the lining membrane of a joint) incision, $25. Tumors extirpation from any part of the body: benign, $15; malignant, $50. Varicose veins-ligation or excision, $25. Varicocele acupressure-ligation or excision, $25. Wounds of scalp or other parts-suturing, $5.