The form contains exclusions and restrictions:

1. (1) It contains none or one or more of the following exclusions and restrictions:

   1. (i) Bodily or mental infirmity or disease of any kind.
   2. (ii) Bodily or mental infirmity or disease of any kind, whether or not the proximate or precipitating cause of death is accidental bodily injury.
   3. (iii) War, declared or undeclared, or an act of war, whether or not serving in the military forces or any civilian noncombatant unit serving with the forces.
   4. (iv) Committing an assault or felony, whether sane or insane.
   5. (v) Participation in a riot or insurrection.
   6. (vi) A fight in which the insured is a voluntary participant.
   7. (vii) Suicide or attempted suicide, whether sane or insane.
   8. (viii) Intentionally self-inflicted injury, whether sane or insane.
   9. (ix) Engaging in an illegal occupation.
   10. (x) Travel or flight in an aircraft or spacecraft, or descent from such a craft while in flight, or subsequent drowning, if the insured is a pilot, officer or crew member of the craft; is giving or receiving aviation training or instruction; has duties on or relating to the craft; or is being flown for the purpose of descent from the craft while in flight.
   11. (xi) Voluntary taking or injection of drugs unless prescribed or administered by a licensed physician. The wording ‘‘taken as prescribed’’ or ‘‘taken in the manner prescribed’’ is not present.
   12. (xii) Voluntary taking or injection of drugs, whether legal or illegal, unless prescribed or administered by a licensed physician. The wording ‘‘taken as prescribed’’ or ‘‘taken in the manner prescribed’’ is not present.
   13. (xiii) The voluntary taking of any drugs prescribed for the insured by a licensed physician and intentionally not taken as prescribed.
   14. (xiv) The voluntary taking of any drugs, whether legal or illegal, prescribed for the insured by a licensed physician and intentionally not taken as prescribed.
   15. (xv) Sensitivity to drugs voluntarily taken, unless prescribed by a physician.
   16. (xvi) Sensitivity to drugs, whether legal or illegal, voluntarily taken, unless prescribed by a physician.
   17. (xvii) Drug addiction, unless addiction results from the voluntary taking of drugs prescribed or administered by a licensed physician or from the involuntary taking of drugs.
   18. (xviii) Drug addiction, unless addiction results from the voluntary taking of drugs, whether legal or illegal, prescribed or administered by a licensed physician or from the involuntary taking of drugs, whether legal or illegal.
   19. (xix) Voluntary taking of any poison except in the case of food poisoning.
   20. (xx) Voluntary taking of any poison except in the case of accidental food poisoning.
   21. (xxi) Voluntary inhaling of any kind of gas, except during the course of employment.
   22. (xxii) Chronic alcoholism.
   23. (xxiii) Directly or indirectly from the voluntary taking of alcohol alone or in combination with a drug, medication or sedative when this action results in legal intoxication as defined by Pennsylvania law. The company provides a certification that the Pennsylvania legal definition for intoxication will be used if the form does not refer to ‘‘intoxication as defined by Pennsylvania law.’’
   24. (xxiv) Medical or surgical treatment.

   25. (xxv) For dismemberment or loss of eyesight, loss must occur within

       days of accidental bodily injury. Note: The specified number of days is not less than 90.

2. (2) The form contains none of the following exclusions and restrictions:

   1. (i) Active duty as a member of the armed forces of any nation.
   2. (ii) Riot or insurrection.
   3. (iii) Participation in a strike.
   4. (iv) Assault provoked by the insured.
   5. (v) Gunshot or pistol wound, unless unintentionally caused by someone else.
   6. (vi) Gunshot or pistol wound, unless intentionally or unintentionally caused by someone else.
   7. (vii) Requiring a visible contusion or wound on the exterior of the body as a result of accidental injury.
   8. (viii) Requiring that accidental bodily injury be evidenced by a visible wound or bruise, except in the case of drowning or internal injuries revealed by an autopsy.
   9. (ix) Loss caused by a foreseeable injury. The noninclusion of this exclusion does not suggest that foreseeability has no bearing on whether a particular loss is due to an accident. Any such determination is the sole responsibility of the courts.
   10. (x) Loss due to accidental means.
   11. (xi) A statement that accidental bodily injuries shall mean injuries caused by external violence.
   12. (xii) Air travel.
   13. (xiii) Air travel, except as a fare paying passenger on a regularly scheduled commercial airline.
   14. (xiv) Travel in any kind of military aircraft or seacraft or aircraft or seacraft operated for the armed forces.
   15. (xv) Illegal drug use.
   16. (xvi) Drug addiction.
   17. (xvii) Involuntary taking of drugs or poison.
   18. (xviii) Voluntary taking of drugs or poison.
   19. (xix) Voluntary inhalation of gas, except while conducting one’s duties during the course of employment.
   20. (xx) Infection occurring as a direct result of accidental bodily injury.
   21. (xxi) Infection, other than a wound caused by an accident.
   22. (xxii) Ptomaine poisoning.
   23. (xxiii) Requiring that death occur within a specified number of days of accidental bodily injury. This does not comply with § 89.43 (relating to accidental death benefit).
   24. (xxiv) Other exclusions or restrictions that are unfair and unduly restrictive.