Deductible                Rate Factors.                   Deductible                 Rate Factors.

US $ Zero  .............   1.25                                  US $500                      .90

 

US $100  ...............   1.10                                  US $1000                    .80

 

US $250.................   1.00                                   US $2500                    .70

All premium rates are in US dollars and are effective through 12/31/2007. Rates include 2.5% surplus lines tax where applicable. A dependent child is your child shown on the Application Form over 14 days and under 18 years of age, traveling with you, and for whom premium has been paid.

POLICY LIMIT		$50,000		$100,000		$500,000		$1,000,000
AGE	Monthly Rates
18-29		$40.00		$46.00		$59.00		$70.00
30-39		$52.00		$62.00		$78.00		$89.00
40-49		$77.00		$88.00		$116.00		$131.00
50-59		$111.00		$135.00		$164.00		$190.00
60-64		$131.00		$160.00		$191.00		$229.00
65-69		$149.00		$192.00		$208.00		$249.00
70-79		$202.00		N/A		N/A		N/A
80+*		$351.00		N/A		N/A		N/A
DEP. CHILD		$24.00		$26.00		$33.00		$36.00
CHILD ALONE		$36.00		$42.00		$54.00		$61.00
	Daily Rates (Minimum length of coverage is 10 days)
18-29		$1.35		$1.55		$2.00		$2.35
30-39		$1.75		$2.05		$2.60		$3.00
40-49		$2.55		$2.95		$3.90		$4.35
50-59		$3.70		$4.55		$5.50		$6.35
60-64		$4.35		$5.35		$6.35		$7.65
65-69		$4.95		$6.40		$6.95		$8.30
70-79		$6.75		N/A		N/A		N/A
80+*		$11.70		N/A		N/A		N/A
DEP. CHILD		$0.80		$0.85		$1.10		$1.20
CHILD ALONE		$1.20		$1.40		$1.80		$2.00

* US$10,000 Maximum


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.
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 US & Canada: No coinsurance For treatment received within the US & Canada: Inside 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. SPECIAL COVERAGES
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 GoTravelSM 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
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,up 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 GoTravelSM 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 GoTravelSM 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. For more information, see the Conditions of Coverage section in the Patriot GoTravelSM brochure.
Terrorism Coverage		Up to US$50,000 lifetime maximum
Each Patriot GoTravelSM 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 GoTravelSM 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. Additional Benefits for U.S. Citizens
Sudden Recurrence of a Pre-existing Condition
Up to US$15,000 will be paid for the eligible expenses of a sudden and unexpected recurrence of a Pre-existing Condition while traveling outside of the US. For the definition of a Pre-existing Condition, please see Exclusion number 1 in the Patriot GoTravelSM brochure.
Indemnity
Patriot GoTravelSM will pay directly to the insured person US$100 for each night of a required overnight stay in a hospital. However, the hospital stay must be covered under this plan in order to receive this benefit.

Exclusions:
Charges for the following services, treatments and/or conditions, among others, are excluded from coverage under the Patriot plans.

1. Pre-existing Conditions. A pre-existing condition is defined as any injury, illness, sickness, disease, or other physical, medical, mental or nervous condition, disorder or ailment that, with reasonable medical certainty, existed at the time of application or at any time during the three years prior to the effective date of the insurance, whether or not previously manifested or symptomatic, diagnosed, treated, or disclosed prior to the effective date, including any subsequent, chronic or recurring complications or consequences related thereto or arising therefrom.
2. Treatment or surgeries which are elective, investigational, experimental or for research purposes.
3. War, military action, terrorism, political insurrection, protest, or any act thereof.
4. Immunizations and routine physical exams.
5. Treatment of Temporomandibular Joint or dental treatment, except as expressly provided for in the certificate of insurance.
6. Venereal disease, AIDS virus, AIDS-related illness, ARC Syndrome, or AIDS, and the cost of testing for these conditions, and charges for treatment or surgeries which are incurred by any Insured who was HIV+ at time of enrollment into this insurance.
7. Pregnancy, childbirth, birth control, artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion.
8. Injury sustained while participating in 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.
9. Vision or ear tests and the provision of visual or hearing aids.
10. Vocational, recreational, speech or music therapy.
11. Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services.
12. Charges, injuries and/or illnesses resulting or arising from or occurring during the commission or continuing perpetration of a violation of law by the insured, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
13. Treatment for, and injuries and/or illnesses resulting or arising from, substance abuse or drug addiction.
14. Injury and/or illness resulting or arising from being under the influence of alcohol or drugs; and injury or illness resulting from operating any type of vehicle after consuming any alcohol or drugs.
15. Willful self-inflicted injury or illness.
16. Treatment required as a result of or arising from complications from a treatment or condition not covered under the certificate.
17. Any services or supplies performed or provided by a relative of the Insured or provided at no cost to Insured.
18. Treatment for mental and nervous disorders.
19. Organ or tissue transplants or related services.
20. Illness or injury where the trip to the host country is undertaken for treatment or advice for such Illness or injury, except as expressly provided for in the certificate of insurance.
21. Treatment incurred as a result of or arising from exposure to nuclear radiation, and/or radioactive material(s).
    

This web page contains only a consolidated and summary description of all current Patriot GoTravel^SM benefits, conditions, limitations and exclusions. A certificate containing the complete Policy Wording with all terms, conditions and exclusions will be included with the fulfillment kit. IMG reserves the right to issue the most current Policy Wording for this insurance plan in the event this application and/or brochure has expired, is modified, or is replaced with a newer version. Current Policy Wordings are available upon request.

Nationwide PPO Network:     Click here to ACCESS THE PPO DIRECTORY

You may seek treatment under Patriot GoTravel Medical Insurance Plan worldwide, including in the United States, with the hospital or doctor of your choice. When seeking treatment in the U.S., you may use the independent Preferred Provider Organization (PPO) contracted by IMG, a separately organized network (First Health Group) of approximately 500,000 physicians and 4,700 privately owned and operated hospitals. * This PPO network includes a large number of hospitals including some of the most well recognized university medical centers and transplant facilities.

Using this provider network could significantly reduce your out-of-pocket expenses.

When a U.S. hospital outside the network is used, a co-payment of US $250 is required in addition to the regular deductible and coinsurance. This co-payment is waived, however, if there is not a network provider within 50 miles of the location of treatment.

Each proposed hospital admission, inpatient or outpatient surgery, and certain other medical procedures must be Pre-certified for medical necessity. This means the insured person or their attending physician must call the number listed on the IMG identification card prior to admittance to a hospital or performance of a surgery, or medical procedure. In the case of an emergency hospital admission, the Pre-certification call must be made within 48 hours of the admission, or as soon as reasonably possible. For a complete list of procedures requiring Pre-certification, please refer to your certificate wording.

If Pre-certification guidelines are not followed, eligible claims and expenses will be reduced by 50%.

FOR ADDITIONAL INFORMATION PLEASE CONTACT:

COMMUNITY INSURANCE AGENCY, INC.
QUALITY SERVICE TO THE COMMUNITY SINCE 1980
425 Huehl Road, Suite 22-A, Northbrook, IL 60062
Ph: 1-847-897-5120 - TOLL FREE PH: 1-800-344-9540
FAX: 1-847-897-5130 - E-mail: info@ciainsagency.com
Website: www.visitorsinsurance.com