• Insurance for up to $1,000,000 in accident and sickness medical expenses, Emergency Medical Evacuation, Medically Necessary Repatriation, Political and Natural Disasters Evacuation, Repatriation of Mortal Remains or Local Burial, Emergency Reunion, $125 Wellness Benefit
• 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. It is not available to green card holders in the USA or to anyone age 90 or above
• This plan is not available to any individual who has been residing within the United States for more than 365 days prior to their Effective Date
• Covers Acute Onset of a Pre-Existing Medical Condition - see below for details
• Coverage from 5 days to 364 days - extensions are available
• Sports activity coverage available

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

Provides coverage for injuries incurred during amateur, Club, Intramural, Interscholastic, Intercollegiate activities such as archery, tennis, swimming, cross country, track, volleyball golf, ballet, basketball, cheerleading, equestrian, fencing, field hockey, football (no division 1), gymnastics, hockey, karate, lacrosse, polo, rowing, rugby and soccer. Any athletic sport not listed is excluded from this policy unless the activity is noncontact and engaged in by you solely for leisure, recreation, entertainment, or fitness purposes only.

Provides coverage for injury or sickness that occurs during an incidental trip to back to your home country or for covered expenses incurred in your home country for conditions first diagnosed outside your home country and treated during your policy period. You must purchase 30 days of coverage to add this benefit.

Plan includes a $10 per person minimum premium

Max Limit: $50,000 - $0 In Network Deductible

Max Limit: $100,000 - $0 In Network Deductible

Max Limit: $250,000 - $0 In Network Deductible

Max Limit: $500,000 - $0 In Network Deductible

Max Limit: $1,000,000 - $0 In Network Deductible

Return to Home Country Coverage:

1.10 x the daily rate

Sports Activity Coverage

Any Sport Activity not expressly covered hereunder is excluded unless the activity is non-contact and engaged solely for leisure, recreation, entertainment, or fitness purposes only.

1.20 x the daily rate + monthly Sports Class rate

• Class 1 Sports: Rate $0 per month
  Archery, Tennis, Swimming, Cross Country, Track, Volleyball & Golf
• Class 2 Sports: Rate $26 per month
  Ballet, Basketball, Cheerleading, Equestrian, Fencing, Field Hockey, Football (no division 1), Gymnastics, Hockey, Karate, Lacrosse, Polo, Rowing, Rugby & Soccer

Accidental Death & Dismemberment:

• $50,000 - $0.25 per day - All Ages
• $100,000 - $0.50 per day- Ages 19-79
• $250,000 - $1.75 per day - Ages 19-69
• $500,000 - $4.00 per day - Ages 19-69

• The effective date is based on the date requested and once payment has been received.
• Plan rates are per person and based on age of traveler at the time of enrollment.
• Plan rates are per person and based on age of traveler at the time of purchase, the Policy Maximum and Out of Network Deductible.
• Coverage from 5 days to 364 days total.
• AUTOMATIC EXTENDED COVERAGE - Coverage will be automatically extended when a 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.
• Apply Online - Accepting Visa, Mastercard, American Express, or Discover

24-hour travel assistance services are provided by On Call International.

This coverage contains a Pre-Existing Condition limitation. “Pre-Existing Condition” means any medical condition, Sickness, Injury, Illness, disease, mental Illness or mental nervous disorder, for which medical advice, diagnosis, care or Treatment was recommended or received or for which a reasonably prudent person would have sought Treatment during the 36-month period immediately preceding the Effective Date of Coverage under this Policy.

Pre-Existing shall also mean any Injury, Illness, Sickness, disease, or other physical, medical, mental or nervous disorder, condition or ailment that, with reasonable medical certainty, existed at the time of Application or at any time during the 36 months prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom.

Pre-Existing shall also include any Acute Onset of an Illness, Sickness, disease, or other physical, medical, mental or nervous disorder, condition or ailment that is an exacerbation of, due to, or associated with an underlying condition. Underlying condition shall include any condition that has been monitored by a Physician due to possible deterioration of the Covered Person's diagnosis being changed, as a result of a previously known condition that can affect, degrade, and/or alter a Covered Person's underlying condition, including any changes in medication. Proof of Eligibility is required prior to any payment of Claim.

Acute Onset of Pre-Existing Condition

For ages up to and including 69 the limit is up to the Medical Policy Maximum purchased per Policy Period except for any coverage related to Cardiac Conditions or Stroke, which will be limited to $25,000. Upon attaining age 70 Acute Onset benefits will be reduced to a Maximum of $35,000 except for any coverage related to Cardiac Conditions or Stroke, which will be limited to $15,000. Benefits are payable up to the maximum provided the condition or event: 1. occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent and immediate medical care; 2. occurs a minimum of 48 hours after the Effective Date of the Policy; and 3. treatment is obtained within 24 hours of the sudden and unexpected outbreak or recurrence. Any repeat/reoccurrence within the same Policy Period will no longer be considered Acute Onset of a Pre-Existing Condition and will not be eligible for additional coverage. This benefit covers only one (1) Acute Onset episode of a Pre-Existing Condition. Sudden and Acute Onset of a Pre-Existing Condition Coverage expires upon medical advice that the condition and onset is no longer acute, or the Covered Person is discharged from a medical facility.

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: a) If any claims have been filed with Us, the premium is fully earned and is non-refundable. b) 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 c) 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.

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 Fairmont Specialty Trust. For a detailed plan description, exclusions, and limitations please view the plan on file with Fairmont Specialty Trust. 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.

FOR ADDITIONAL INFORMATION

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

Version: 10/12/2022
AH-4528