(a) Accidental death.

1. (1) The form discloses that a stated benefit amount will be paid if the insured’s death results from an accident.
2. (2) The form discloses age requirements as to when the insured is eligible for benefits and when eligibility terminates.
3. (3) Children aged 5 and under are or are not excluded from eligibility.
4. (4) Eligibility will or will not be terminated for all insureds after age 65.
5. (5) The form discloses the conditions for payment of the accidental death benefit. The death results from an accident occurring during the coverage period.

6. (6) Death also:

   1. (i) Results from accidental bodily injury, directly and independently of all other causes.
   2. (ii) Occurs after the effective date of coverage.
   3. (iii) Occurs while the rider and policy, or the policy alone in the case of a built-in benefit, are in force.

(b) Additional indemnity.

1. (1) The form provides for an accidental death benefit payment equal to a specified amount or to a multiple of the benefit amount when death results from a specified accidental cause; for example—accidental injury that occurs while the insured is a fare paying passenger on a public conveyance.
2. (2) The form provides for an accidental death benefit payment equal to a specified amount or to a multiple of the benefit amount if death is the result of an automobile accident and the insured person was wearing a seatbelt at the time of the accident.

(c) Loss of limbs or eyesight.

1. (1) The form provides for a benefit equal to a specified amount or to a fraction or multiple of the benefit amount for one or more of the following:

   1. (i) An accidental dismemberment.
   2. (ii) The loss of use of limbs.
   3. (iii) The loss of eyesight.
2. (2) The form does not require that accidental dismemberment, loss of use of limbs or loss of eyesight be caused by injury sustained or occurring or disease manifesting itself after the effective date of the form.