Safe Travels Elite

Scheduled Benefits Accident and Sickness Medical Coverage

INCLUDING medically necessary treatment for COVID-19, SARS-CoV2, and any mutation or variant of SARS-CoV2.
Emergency Medical Evacuation and Repatriation coverage.
For NON-US Citizens/Residents traveling from other countries to USA or USA worldwide.
Plans available for ages 14 days to 89 years.
A minimum period of 5 days up to a maximum period of 364 days.

Plan Benefits	Safe Travels Elite Economy	Safe Travels Elite Basic	Safe Travels Elite Silver	Safe Travels Elite Gold	Safe Travels Elite Platinum	Safe Travels Elite Diamond	Safe Travels Elite Diamond Plus
Policy Maximum	$25,000 Max per Incident	$50,000 Max per Incident	$75,000 Max per Incident	$100,000 Max per Incident	$175,000 Max per Incident	$50,000 Annual Max.	$100,000 Annual Max.
Deductible Per Incident	$0	$0	$0	$0	$0	$100, $200	$100, $200
Ages	Ages 0-69	Ages 0-69	Ages 0-69	Ages 0-69	Ages 0-69	Ages 70-89	Ages 70-89
Inpatient Hospital Expense
Hospital Room and Board Expenses	$1,400 per day to a maximum of 30 days	$2,000 per day to a maximum of 30 days	$2,000 per day to a maximum of 30 days	$2,000 per day to a maximum of 30 days	$3,000 per day to a maximum of 30 days	$1,500 per day to a maximum of 30 days	$1,500 per day to a maximum of 30 days
Inpatient Ancillary Hospital Services	Included under the Hospital Room and Board	Included under the Hospital Room and Board	Included under the Hospital Room and Board	Included under the Hospital Room and Board	Included under the Hospital Room and Board	Included under the Hospital Room and Board	Included under the Hospital Room and Board
Hospital Intensive Care Unit Expenses	$2,100 per day to a maximum of 10 days	$2,500 per day to a maximum of 8 days	$2,500 per day to a maximum of 8 days	$3,000 per day to a maximum of 8 days	$4,500 per day to a maximum of 8 days	$2,300 per day to a maximum of 8 days	$2,300 per day to a maximum of 8 days
Physician's Surgical Treatment	$3,500 per Incident	$5,000 per Incident	$5,000 per Incident	$6,000 per Incident	$7,500 per Incident	$3,500 per Incident	$3,500 per Incident
Anesthesiologist Expense	$850 per Incident	$850 per Incident	$1,200 per Incident	$1,400 per Incident	$1,800 per Incident	$850 per Incident	$850 per Incident
Assistant Physician’s Surgical Expenses	$850 per Incident	$850 per Incident	$1,200 per Incident	$1,400 per Incident	$1,800 per Incident	$850 per Incident	$850 per Incident
Physician's Non-Surgical Visits	Limited to $55 per visit, one visit per day and 30 visits per Policy Period	Limited to $75 per visit, one visit per day and 30 visits per Policy Period	Limited to $75 per visit, one visit per day and 30 visits per Policy Period	Limited to $100 per visit, one visit per day and 30 visits per Policy Period	Limited to $130 per visit, one visit per day and 30 visits per Policy Period	Limited to $75 per visit, one visit per day and 30 visits per Policy Period	Limited to $75 per visit, one visit per day and 30 visits per Policy Period
Physician's Surgical Treatment	$3,500 Incident	$5,000 per Incident	$5,000 per Incident	$6,000 per Incident	$7,500 per Incident	$3,500 per Incident	$3,500 per Incident
Consulting Physician	$450 per Incident	$450 per Incident	$550 per Incident	$550 per Incident	$700 per Incident	$450 per Incident	$450 per Incident
Private Duty Nurse	$450 per Incident	$450 per Incident	$550 per Incident	$550 per Incident	$700 per Incident	$450 per Incident	$450 per Incident
Pre-Admission Tests within 7 days of Admission	$1,100 per Incident	$1,100 per Incident	$1,100 per Incident	$1,200 per Incident	$1,500 per Incident	$1,100 per Incident	$1,100 per Incident
Outpatient - Maximum Daily Benefit All Services $10,000 - up to the selected Policy Maximum
Outpatient Surgical Facility	$1,000 per Incident	$1,100 per Incident	$1,150 per Incident	$1,275 per Incident	$1,400 per Incident	$1,100 per Incident	$1,100 per Incident
Pre-Admission Test within 7 days of Admission	$3,500 per Incident	$5,000 per Incident	$5,000 per Incident	$6,000 per Incident	$7,500 per Incident	$3,500 per Incident	$3,500 per Incident
Anesthesiologist Expense	$850 per Incident	$850 per Incident	$1,200 per Incident	$1,400 per Incident	$1,800 per Incident	$700 per Incident	$700 per Incident
Assistant Physician’s Surgical Expenses	$850 per Incident	$850 per Incident	$1,200 per Incident	$1,400 per Incident	$1,800 per Incident	$700 per Incident	$700 per Incident
Physician's Visits/Urgent Care	Limited to $55 per visit, one visit per day and 30 visits per Policy Period	Limited to $75 per visit, one visit per day and 30 visits per Policy Period	Limited to $75 per visit, one visit per day and 30 visits per Policy Period	Limited to $100 per visit, one visit per day and 30 visits per Policy Period	Limited to $130 per visit, one visit per day and 30 visits per Policy Period	Limited to $75 per visit, one visit per day and 30 visits per Policy Period	Limited to $75 per visit, one visit per day and 30 visits per Policy Period
Diagnostic X-Rays and Lab Services	$450 per Incident	$750 per Incident	$750 per Incident	$750 per Incident	$1,000 per Incident	$750 per Incident	$750 per Incident
Chemotherapy &/or radiation therapy	$1,100 per Incident	$1,100 per Incident	$1,225 per Incident	$1,350 per Incident	$1,750 per Incident	$700 per Incident	$1,100 per Incident
Scans, PET Scan or MRI	$650 per Incident	$650 per Incident	$875 per Incident	$1,050 per Incident	$1,300 per Incident	$650 per Incident	$650 per Incident
Emergency Room Illness with no direct Hospital Admission	$350 and an additional $200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.	$500 and an additional $200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.	$500 and an additional $200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.	$600 and an additional $200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.	$800 and an additional $200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.	$500 and an additional $200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.	$500 and an additional $200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.
Emergency Room injury/Accident or Illness with direct Hospital Admission	$350 per Incident	$500 per Incident	$500 per Incident	$600 per Incident	$800 per Incident	$500 per Incident	$500 per Incident
Prescription drugs and medications	$250 per Incident	$350 per Incident	$350 per Incident	$350 per Incident	$350 per Incident	$250 per Incident	$250 per Incident
Additional Medical Treatment and Services
Acute Onset of Pre-Existing Condition(s) per Policy Period Subject to the sub limits for each benefit listed	Up to Policy Maximum Coverage related to Cardiac Conditions or Stroke are limited to $25,000	Up to Policy Maximum Coverage related to Cardiac Conditions or Stroke are limited to $25,000	Up to Policy Maximum Coverage related to Cardiac Conditions or Stroke are limited to $25,000	Up to Policy Maximum Coverage related to Cardiac Conditions or Stroke are limited to $25,000	Up to Policy MaximumCoverage related to Cardiac Conditions or Stroke are limited to $25,000	For ages 70-79, up to $25,000. For ages 80 and above, up to $15,000. Coverage related to Cardiac Conditions or Stroke are limited to $15,000	For ages 70-79, up to $25,000. For ages 80 and above, up to $15,000. Coverage related to Cardiac Conditions or Stroke are limited to $15,000
Cardiac Conditions	$25,000 per Policy Period	$25,000 per Policy Period	$25,000 per Policy Period	$25,000 per Policy Period	$25,000 per Policy Period	$15,000 per Policy Period	Coverage related to Cardiac Conditions or Stroke are limited to $15,000
Covid-19 Expenses	Covered as any other Sickness	Covered as any other Sickness	Covered as any other Sickness	Covered as any other Sickness	Covered as any other Sickness	Covered as any other Sickness	Covered as any other Sickness
Well Doctor Visit	Pays up to $125 - One Visit per person per Policy Period. The Well Doctor Visit must occur within the first 21 days from the effective date of coverage. To be eligible you must purchase at least 30 days of coverage initially.
Dental Treatment for Injury to sound, natural teeth	$600 per Incident	$750 per Incident	$750 per Incident	$750 per Incident	$750 per Incident	$750 per Incident	$750 per Incident
Mental or Nervous Disorder & Substance Abuse treatment	$5,000 per Incident	$5,000 per Incident	$5,000 per Incident	$5,000 per Incident	$5,000 per Incident	$5,000 per Incident	$5,000 per Incident
Physiotherapy Physical Medicine/Chiropractic Expenses	$40/visit, 1/day, 12 visits max per Policy Period	Limited to $50 per visit, one visit per day and 12 visits per Policy Period	Limited to $50 per visit, one visit per day and 12 visits per Policy Period	Limited to $60 per visit, one visit per day and 12 visits per Policy Period	Limited to $60 per visit, one visit per day and 12 visits per Policy Period	Limited to $50 per visit, one visit per day and 12 visits per Policy Period	Limited to $50 per visit, one visit per day and 12 visits per Policy Period
Initial Orthopedic Prosthesis/brace	$1,100 per Incident	$1,100 per Incident	$1,225 per Incident	$1,350 per Incident	$1,750 per Incident	$1,100 per Incident	$1,100 per Incident
Return to Home Coverage	Up to 30 days per 12 months Max $2,000	Up to 30 days per 12 months Max $2,000	Up to 60 days per 12 months Max $2,500	Up to 60 days per 12 months Max $2,500	Up to 90 days per 12 months Max $7,500	N/A	N/A
Transportation Expenses
Ambulance Service Benefits	$500 per Incident	$650 per Incident	$650 per Incident	$650 per Incident	$750 per Incident	$650 per Incident	$650 per Incident
*Emergency Medical Evacuation	$100,000 per Policy Period	$100,000 per Policy Period	$100,000 per Policy Period	Unlimited	Unlimited	$50,000 and $25,000 Lifetime Maximum for Acute Onset over age of 80	$50,000 and $25,000 Lifetime Maximum for Acute Onset over age of 80
*Medically Necessary Repatriation	$15,000 per Policy Period	$15,000 per Policy Period	$15,000 per Policy Period	$15,000 per Policy Period	$15,000 per Policy Period	$15,000 per Policy Period	$15,000 per Policy Period
*Political Evaluation	$500 per Policy Period	$500 per Policy Period	$500 per Policy Period	$500 per Policy Period	$500 per Policy Period	$500 per Policy Period	$500 per Policy Period
*Natural Disasters Evacuation	$5,000 per Policy Period	$5,000 per Policy Period	$7,500 per Policy Period	$7,500 per Policy Period	$10,000 per Policy Period	$5,000 per Policy Period	$5,000 per Policy Period
*Return of Minor Children or Grandchildren	$2,100 per day to a maximum of 10 days	$2,500 per day to a maximum of 8 days	$2,500 per day to a maximum of 8 days	$3,000 per day to a maximum of 8 days	$4,500 per day to a maximum of 8 days	$2,300 per day to a maximum of 8 days	$2,300 per day to a maximum of 8 days
*Repatriation of Mortal Remains	$7,500 per Policy Period	$7,500 per Policy Period	$10,000 per Policy Period	$20,000 per Policy Period	$25,000 per Policy Period	$7,500 per Policy Period	$7,500 per Policy Period
*Local Burial/Cremation	$5,000 per Policy Period	$5,000 per Policy Period	$5,000 per Policy Period	$5,000 per Policy Period	$5,000 per Policy Period	$5,000 per Policy Period	$5,000 per Policy Period
Additional Benefits
*Common Carrier AD&D	$25,000 Principal Sum	$25,000 Principal Sum	$35,000 Principal Sum	$35,000 Principal Sum	$35,000 Principal Sum	N/A	N/A
*Felonious Assault AD&D	$5,000 Principal Sum	$5,000 Principal Sum	$7,500 Principal Sum	$7,500 Principal Sum	$10,000 Principal Sum	$5,000 Principal Sum	$5,000 Principal Sum
Additional Services
**Telemedicine	https://www.insubuy.com/safe-travels-telemedicine/	https://www.insubuy.com/safe-travels-telemedicine/	https://www.insubuy.com/safe-travels-telemedicine/	https://www.insubuy.com/safe-travels-telemedicine/	https://www.insubuy.com/safe-travels-telemedicine/	https://www.insubuy.com/safe-travels-telemedicine/	https://www.insubuy.com/safe-travels-telemedicine/
**Travel Assistance	Included	Included	Included	Included	Included	Included	Included

*Not subject to the Medical Deductible
**This is a non-insurance service and is not a part of the insurance underwritten by Crum & Forster, SPC.

This is brief summary of the features available in this plan. It is not a contract of insurance. This plan includes both insurance and non-insurance benefits. Limitations and exclusions apply.

General Terms of Coverage

Eligibility

This plan provides coverage to non-US citizens who reside outside the USA and are traveling outside of Their Home Country to visit solely the United States, or to visit a combination of the United States and other countries worldwide. The Insured must arrive in the USA before traveling to other countries. This Policy is not available to green card holders in the USA. Please note maximum age restrictions by plan. This Policy is not available to anyone age 90 or above. This policy is not available to any individual who has been residing within the United States for more than 365 days prior to their Effective Date. We maintain Our right to investigate to verify that the eligibility requirements have been met. If and whenever We discover that the eligibility requirements have not been met, Our only obligation is refund of premium.

Benefit Period

While the Policy is in effect, we will pay eligible medical expenses for up to 180 days beginning on the first day of diagnosis or treatment of a covered Sickness or Injury; or
Upon termination of the Policy, provided the Covered Person remains outside their Home Country and has not traveled back to their Home Country, we will continue to pay eligible medical expenses; up to 2 days following your Termination Date; or for up to 180 days beginning on the first day of diagnosis or treatment of a covered Sickness or Injury; or up to the maximum as stated under the Policy Medical Maximum; whichever occurs first; or
Upon termination of the Policy, whereas the Covered Person returns to their Home Country the Benefit Period shall discontinue on the date of termination and the plan will no longer pay eligible medical expenses.

Effective Date

An eligible person will be insured on the latest of the following dates: 1. the Covered Person’s departure from Their Home Country; 2. the date and time the Covered Person completed enrollment form and Their correct premium is received; or 3. the Effective Date requested and shown on the certificate.

Termination Date

Coverage will end on the earliest of the date:

the Covered Person’s return to Their Home Country, except as provided under Return to Home Country Benefit, if eligible; or
the day after the Termination Date shown on the certificate for which premium has been paid; or
Three hundred and sixty-four (364) days after the Covered Person's original effective date; or
The date the Covered Person becomes a United States citizen; or
The date the Covered Person is no longer eligible for this plan; or
the date the Maximum Benefit for the loss has been paid.

Automatic Extended Coverage

Coverage will be automatically extended

If Your scheduled return is delayed due to unavoidable circumstances beyond Your control. This extension of coverage will end on the earlier of the date You reach Your originally scheduled date to return or 5 days after the Termination Date.
If You incur a covered Injury or Sickness on Your Trip and a treating Physician certifies that You are not Medically Fit to Travel to Your Home Country on Your Termination Date, the Medical Evacuation and Repatriation benefit will be automatically extended for 30 days or until You are Medically Fit to Travel and transported to Your Home Country or You reached the Maximum Benefit Amount shown in the Schedule of Benefits, whichever is sooner.

If You are Hospitalized due to a covered Injury or Sickness on Your Termination Date and a treating Physician certifies that You are not Medically Fit to Travel on Your Termination Date, this plan will be extended for an additional 30 days, or until You are released from the Hospital and Medically Fit to Travel, or You reached the Maximum Benefit Amount shown in the Schedule of Benefits, whichever is sooner.

Optional Extension Procedures

An extension notice will be sent to the Covered Person before the Policy Period ends and includes links to extend prior to the Termination Date. The Covered Person is subject to the following rules at extension: In order to extend, the Policy Period must be initially purchased for a minimum of 5 days. If available, an extension period can be purchased

at the premium rate in force at the time of the extension;
or a minimum of 5 days;
for up to a maximum of 364 days, provided the Covered Person’s Policy Period does not exceed 364 days in total.

There are no grace periods for extension. Once the policy has lapsed, reapplication is required. Please note, upon application for a new policy, the Pre-Existing Condition exclusion, deductible and co-insurance start over.

Cancellation and Refund Procedure Provisions

Full cancellation and refund will only be considered if We receive written request prior to or on the Effective Date of the coverage. If We receive a written request for cancellation and refund after the Effective Date of coverage, a partial cancellation and refund may be allowed.

The following conditions apply

If any claims have been filed with Us, the premium is fully earned and is non-refundable. If no claims have been filed with the Company, then (i) a cancellation fee of US $25 will be charged; and (ii) only unused days
premiums will be considered as refundable; and
If after a refund is made, it is determined that a claim was presented to Us on a Covered Person’s behalf, the Covered Person will be fully responsible for that claim in its entirety.

On Call International Travel Assistance Services

The Travel Assistance program feature provides a variety of travel related services that include, Medical Monitoring Medical, Dental and Pharmacy Referrals, and Hospital Admission Guarantee. Travel assistance services are provided by an independent organization and not by the Company. There may be times when circumstances beyond On Call’s control hinder their endeavors to provide travel assistance services. They will, however, make all reasonable efforts to provide travel assistance services and help you resolve your emergency situation.

Telemedicine

Telemedicine is provided is a non-insurance service and is not a part of the insurance underwritten by Crum & Forster, SPC.

To qualify you must contact the Assistance Provider directly for service. Please use this link for details https://www.insubuy.com/safe-travels-telemedicine/

Disclosures Client must notify the Plan Administrator within 30 days of a change of address or domicile.

Rates

Safe Travels Elite Rates Per Person Per Day	Economy	Basic	Silver	Gold	Platinum	Diamond	Diamond	Diamond Plus	Diamond Plus
Policy Max	$25,000	$50,000	$75,000	$100,000	$175,000	$50,000	$50,000	$100,000	$100,000
Deductible	$0	$0	$0	$0	$0	$100	$200	$100	$200
0-17	$0.65	$1.05	$1.32	$1.47	$2.12	N/A	N/A	N/A	N/A
18-29	$0.65	$1.05	$1.32	$1.47	$1.98	N/A	N/A	N/A	N/A
30-39	$0.73	$1.22	$1.46	$1.62	$2.11	N/A	N/A	N/A	N/A
40-49	$0.76	$1.26	$1.49	$1.65	$2.19	N/A	N/A	N/A	N/A
50-59	$1.08	$1.75	$2.10	$2.34	$3.28	N/A	N/A	N/A	N/A
60-64	$1.43	$2.21	$2.61	$2.90	$3.85	N/A	N/A	N/A	N/A
65-69	$1.43	$2.21	$2.61	$2.90	$3.85	N/A	N/A	N/A	N/A
70-74	N/A	N/A	N/A	N/A	N/A	$3.14	$2.96	$4.46	$4.35
75-79	N/A	N/A	N/A	N/A	N/A	$3.14	$2.96	$4.46	$4.35
80-84	N/A	N/A	N/A	N/A	N/A	$8.16	$6.81	$15.94	$13.13
85-90	N/A	N/A	N/A	N/A	N/A	$10.00	$8.50	$22.50	$19.69

Notice

Please keep this Brochure as a brief description of the important features of the plan. It is not a contract of insurance. This plan includes both insurance and non-insurance benefits. The terms and conditions of coverage are set forth in the Plan issued to with Fairmont Specialty Trust, LTD. For a detailed plan description, exclusions, and limitations please view the plan on file with Fairmont Specialty Trust, LTD. The Policy contains a complete description of all of the terms, conditions, and exclusions of the insurance plan as underwritten by Crum & Forster SPC. The Policy will prevail in the event of any discrepancy between this Brochure and the Policy.

Note:

This insurance is not subject to and does not provide certain insurance benefits required by the United States’ Patient Protection and Affordable Care Act (“PPACA”). PPACA requires certain US citizens or US residents to obtain PPACA compliant health insurance, or “minimum essential coverage.” PPACA also requires certain employers to offer PPACA compliant insurance coverage to their employees. Tax penalties may be imposed on U.S. residents or citizens who do not maintain minimum essential coverage, and on certain employers who do not offer PPACA compliant insurance coverage to their employees. In some cases, certain individuals may be deemed to have minimum essential coverage under PPACA even if their insurance coverage does not provide all of the benefits required by PPACA. You should consult your attorney or tax professional to determine whether the policy meets any obligations you may have under PPACA.

Privacy Statement

We know that your privacy is important to you and we strive to protect the confidentiality of your non-public personal information. We do not disclose any non-public personal information about our insureds or former insureds to anyone, except as permitted or required by law. We maintain appropriate physical, electronic and procedural safeguards to ensure the security of your non-public personal information.

Complaints

In the event that you remain dissatisfied and wish to make a complaint you can do so to the Complaints team at Co-Ordinated Benefit Plans.

Data Protection

Please note that sensitive health and other information that you provide may be used by us, our representatives, the insurers and industry governing bodies and regulators to process your insurance, handle claims and prevent fraud. This may involve transferring information to other countries (some of which may have limited, or no data protection laws). We have taken steps to ensure your information is held securely. Where sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use as set out above. Information we hold will not be shared with third parties for marketing purposes. You have the right to access your personal records.

By purchasing this insurance provided by Crum & Forster SPC, under the jurisdiction of the Cayman Islands, you become a member of the Fairmont Specialty Trust.

Administrator

Trawick International Inc.
Post Office Box 2284
Fairhope, AL 36533

Underwriter

Co-Ordinated Benefit Plans, LLC on Behalf of Crum and Forster
PO Box 2069
Fairhope, AL 36533

FOR ADDITIONAL INFORMATION

Insubuy^®, LLC.
4200 Mapleshade Ln, Suite 200
Plano, TX 75093

Toll Free: +1 (866) INSUBUY
Phone: +1 (972) 985-4400
Fax: +1 (972) 767-4470
Website: www.insubuy.com

Version: AH-4530
10/12/2022

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Scheduled Benefits Accident and Sickness Medical Coverage

General Terms of Coverage

Eligibility

Benefit Period

Effective Date

Termination Date

Automatic Extended Coverage

Optional Extension Procedures

Cancellation and Refund Procedure Provisions

On Call International Travel Assistance Services

Telemedicine

Rates

Notice

Note:

Privacy Statement

Complaints

Data Protection

Administrator

Underwriter

FOR ADDITIONAL INFORMATION

Did you know?

Why purchase insurance from Insubuy^®?

Visiting USA?

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New immigrant to USA?

Going on a vacation?

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International student in the U.S.?

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Safe Travels Elite

Scheduled Benefits Accident and Sickness Medical Coverage

General Terms of Coverage

Eligibility

Benefit Period

Effective Date

Termination Date

Automatic Extended Coverage

Optional Extension Procedures

Cancellation and Refund Procedure Provisions

On Call International Travel Assistance Services

Telemedicine

Rates

Notice

Note:

Privacy Statement

Complaints

Data Protection

Administrator

Underwriter

FOR ADDITIONAL INFORMATION

Did you know?

Why purchase insurance from Insubuy®?

Visiting USA?

Traveling abroad?

New immigrant to USA?

Going on a vacation?

Are you an exchange visitor to USA?

Traveling to Europe?

Traveling frequently throughout the year?

International student in the U.S.?

Why purchase insurance from Insubuy^®?