SCHEDULE OF BENEFITS

MEDICAL BENEFITS

Usual, reasonable and customary charges, subject to deductible and coinsurance

Hospital Room and Board

Up to Policy Maximum for average semi-private room rate

Intensive Care

Up to Policy Maximum

Medical Expenses

Up to Policy Maximum

Outpatient Medical

Up to Policy Maximum

Local Ambulance

Up to Policy Maximum

Emergency Room

As described below

Charges incurred for the use of the Emergency Room due to an accident are covered up to the Policy Maximum.

Charges incurred for the use of the Emergency Room for treatment of an illness are subject to an additional (extra) US$250 deductible if treatment does not require admittance to the hospital.

Dental

As described below

Injury due to an accident: Each Patriot plan covers the cost of emergency dental treatment and dental procedures necessary to restore sound natural teeth lost or damaged in an accident up to the Policy Maximum.

Sudden dental pain: Each plan will pay up to US$100 for the necessary treatment of sudden, unexpected pain to sound natural teeth.

INTERNATIONAL EMERGENCY CARE

Emergency Evacuation

Up to Policy Maximum when coordinated through the Plan Administrator

Each Patriot plan includes coverage for Emergency Medical Evacuations to the nearest qualified medical facility; expenses for reasonable travel and accommodations resulting from the evacuation; and the cost of returning to either the home country or the country where the evacuation occurred, up to the Policy Limit.

Emergency Reunion

Up to US$15,000 when coordinated through the Plan Administrator

Each Patriot plan also provides emergency reunion coverage, up to US$15,000 for a maximum of 15 days, for the reasonable travel and lodging expenses of a relative or friend during an Emergency Medical
Evacuation: either the cost of accompanying the insured during the evacuation or traveling from the home country to be reunited with the insured.

Return of Mortal Remains

Up to US$25,000 when coordinated through the Plan Administrator

If a covered illness/injury results in death, expenses for Repatriation of bodily remains or ashes to the home country will be covered up to a maximum of US$25,000.

Returning Minor Children

Up to US$5,000 when coordinated through the Plan Administrator

If an insured person is hospitalized due to a covered illness/injury and is traveling alone with child (ren) 19 or under that otherwise would be left unattended, the Patriot plans will pay up to US$5,000 for one way economy fare to their home country, including a chaperone, if necessary, for the safety of the child (ren).

Political Evacuation

Up to US$10,000 when coordinated through the Plan Administrator

If the United States Department of State, Bureau of Consular Affairs issues a travel advisory that becomes effective on or after the Insured Person’s date of arrival in the Host Country, the Company will pay up to US$10,000 for transportation to the nearest place of safety or for repatriation to the Insured Person’s home country or country of residence provided that:

1.               The Insured Person contacts the Company within 10 days of the United States Department of State, Bureau of Consular affairs issues the travel advisory;

2.               Political Evacuation and Repatriation is approved and coordinated by the Company.

PLAN INFORMATION

Deductible

Your choice of US$0, $100, $250, $500, $1,000 or $2,500

On the Application Form, you will be asked to circle your choice of a deductible. Your premium rate is dependent on the deductible you choose. Please see the Application Form for more information.

Coinsurance

As described below

For treatment received outside the U.S. & Canada: No coinsurance

For treatment received within the U.S. & Canada:
In the PPO Network:  The plan pays 90% of eligible expenses up to US$5,000, then 100% up to the Policy Maximum

Outside the PPO Network:  The plan pays 80% of eligible expenses up to US$5,000, then 100% up to the Policy Maximum

Benefit Period

Six months

If a covered injury or illness requires continuing treatment after the Period of Coverage expires, the six-month Benefit Period may provide continued coverage. When the certificate expires, the Company will review the date of initial treatment for the covered injury or illness. If treatment began less than six months before the Period of Coverage expired, benefits for the covered injury or illness will continue subject to the Policy Limits and the other terms of the plan until there have been six months of continuous coverage for the covered injury or illness.

ADDITIONAL BENEFITS

Home Country Coverage

As described below

Incidental Home Country Coverage - During the Period of Coverage an insured person may return to their home country for incidental visits up to a cumulative two weeks total, subject to: a. The insured person must have left their home country, b. The total Period of Coverage must be for a minimum of 30 days, and c. The return to the home country may not be taken to receive treatment for an illness or injury incurred while traveling.

End of Trip Home Country Coverage - For every five months of continuous coverage you purchase, you can purchase one additional month of home country coverage as an accommodation and supplemental travel benefit, up to a maximum of two months. To purchase this special home country extension coverage, please check the appropriate box on the Application Form, and calculate your premium to include the additional month(s).

Trip Interruption

Up to US$5,000

If, during a covered trip, there is a death of an immediate family member (spouse, child, parent or sibling) or the substantial destruction of the insured’s principal residence, each Patriot plan will pay to return the insured to the area of principal residence. The plan will pay for a one way air or ground transportation ticket of the same class as the unused travel ticket, less the value of the unused return ticket.

Lost Luggage

Up to US$50 per item or personal property; maximum of US$250 per Period of Coverage

This benefit will be paid in the event that the Common Carrier permanently loses an insured person’s checked luggage. This coverage is secondary to any other available coverage, including the Carrier’s.

Common Carrier Accidental Death

US$50,000 to Beneficiary; maximum of US$250,000 per family

If accidental death should occur while traveling on a commercial Common Carrier, US$50,000 will be paid to the designated beneficiary, to a maximum of US$250,000 per family.

Sports & Activities Coverage

Up to Policy Maximum for basic sports Coverage as described below

Each Patriot plan covers injuries incurred during amateur athletic activities, which are non-contact and engaged in by the insured person solely for leisure, recreation, entertainment or fitness purposes. However, activities not covered include amateur or professional sports or other athletic activity which is organized and/or sanctioned, or which involves regular or scheduled practices, games or competition.

The following hazardous activities are excluded: racing of any kind, aviation (except when traveling as a passenger in a commercial aircraft), BMX, BASE jumping, bobsleigh, bungee jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning, inline skating, jet skiing, kayaking, luge, motocross (moto-x), mountain biking, mountaineering, parachuting, rappelling, rock climbing, rodeo, scuba diving, ski jumping, sky diving, snow skiing, snowboarding, snowmobiling, spelunking, snorkeling, surfing, wakeboarding, water skiing, windsurfing and whitewater rafting.

Optional Leisure or Extreme Sports Riders: Please see the brochure for more information.

Accidental Death & Dismemberment

US$25,000 principal sum

Each Patriot plan includes US$25,000 principal sum benefit for Accidental Death and Dismemberment occurring during the Period of Coverage: • Accidental Loss of life - principal sum; • Accidental Loss of two Members - principal sum; • Accidental Loss of one Member - 50% of principal sum. “Member” means hand, foot or eye.

Terrorism Coverage

Up to US$50,000 lifetime maximum

Each Patriot plan provides coverage for injuries and illness incurred as a result of an act of Terrorism, limited in amount and by circumstances. If an insured person is injured as a result of an act of Terrorism, and the insured person has no direct or indirect participation in the act, the plan will reimburse eligible medical claims subject to a US$50,000 lifetime maximum. However, claims incurred as a result of radiological, nuclear, chemical or biological weapons or events are not covered.

Terrorism is defined as the systematic or planned use of violence, fear, or threat of violence in order to intimidate a population or government, especially as a means of coercion or to obtain a granting of any demand. However, this benefit does not cover an act of Terrorism in any country or location where the United States government has issued a travel advisory that has been in effect within the 6 months prior to the insured person's date of arrival.

This benefit also does not cover an act of Terrorism in the event that an advisory to leave a certain country or location is issued by the United States government after the insured person's arrival date, and the insured person unreasonably fails or refuses to depart the country or location.

Identity Theft Assistance

Up to US$500 per Period of Coverage

If an imposter obtains key personal information such as a Social Security or Driver's License number, or other method of identifying an insured person in order to impersonate or obtain credit, merchandise or services in the insured person’s name, the Patriot plans will provide coverage for the reasonable, customary and necessary costs incurred by the insured for: re-filing a loan or other credit application that is rejected solely as a result of the stolen identity event; notarization of legal documents, long-distance telephone calls, and postage that has resulted solely as a result of reporting, amending and/or rectifying records as a result of the stolen identity event; up to three credit reports obtained within one year of the insured person’s knowledge of the stolen identity event; and stop payment orders placed on missing or unauthorized checks as a result of the stolen identity event.

The identity theft event must occur during the Period of Coverage and must be reported within 6 months of the termination of coverage date.

LEISURE SPORTS RIDER

The Leisure Sports Rider is available on both Patriot plans and adds coverage for jet skiing, scuba diving, snow skiing, snowboarding, snowmobiling, snorkeling, surfing, wakeboarding, water skiing and windsurfing. For premium information, please see the back of the Application Form.

Base Premium x 20%

EXTREME SPORTS RIDER

The Extreme Sports Rider is available on both Patriot plans and adds up to 12 months of coverage for those under the age of 49. This rider provides up to US$50,000 lifetime maximum for the following activities: abseiling, BMX, bungee jumping, canyoning, caving, flying (private plane), hang gliding, heli-skiing, high diving, hot air ballooning, kayaking, inline skating, mountain biking, mountaineering (ropes and guides to 4500m from ground level), paragliding, parascending, rappelling, rock climbing (ropes and guides to 4500m from ground level), skydiving, spelunking, whitewater rafting (to Class V). These extreme activities must be engaged in solely for leisure, recreation, or entertainment purposes.

Monthly rates - Available in monthly increments up to a maximum of 12 months.

U.S. Citizen
US$30

Non-U.S. Citizen
US$45

PATRIOT RETURN RIDER

The Patriot Return Rider is only available to non-U.S. citizens who have purchased Patriot America. When purchased at the time of application, Patriot Return provides temporary medical coverage for non-U.S. citizens returning to their home country. The insured person must be outside his/her home country at time of application.

Base Premium x 5%

Up to US$100,000 additional coverage
Up to US$200,000 additional coverage
Up to US$300,000 additional coverage
Up to US$400,000 additional coverage

US$8
US$16
US$24
US$32

PATRIOT T.R.I.P. LITE^SM

Trip cancellation coverage is available and can be purchased for your trip. With this plan, the loss of pre-paid, nonrefundable, and unused payments may be recovered when a trip is cancelled due to: illness, injury or death to you, a family member or travel companion; bankruptcy or financial default; a terrorist incident; jury duty; home made uninhabitable by fire, wind, storm, flood, or vandalism; quarantine; auto accident on way to airport; job termination; cancelled leave for active duty military, police or fire fighters.

Benefits

Maximum benefit per insured person