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LIAISON
International
Medical Insurance That Covers You Outside Your Home Country
Brochure and Application for the year 2002
15 DAYS TO 3 YEARS OF COVERAGE FOR:
SCHEDULE
OF COVERAGE
All
coverages and plan costs listed in this brochure are in U.S. dollar amounts
| Policy Maximum: | $50,000; $100,000; $500,000; $1,000,000 (ages 80+, maximum limited to $15,000) |
| Deductible: | $100; $250; $500; $1000; $2500 Deductible is per person per policy period, maximum of 3 Policy Period deductibles per family. The selected Deductible and Coinsurance amount must be met for each 12-month period (see Continuing Coverage) |
| Coinsurance: |
Inside
the United States and Canada: After the Insured pays the deductible, the
program pays 80% of the next $5,000 of eligible expenses, then 100% to the
selected Maximum.
Outside the United States and Canada: After the Insured pays the deductible, the program pays 100% to the selected Maximum. |
| Hospital Indemnity: | $100 / night (traveling outside the US and Canada) In addition to any other Covered Expense. |
| Dental (Emergency): | $100 or ($500 for accidents) Only available to programs purchased for 1 month or more. |
| Emergency Medical Evacuation / Repatriation: | $100,000 |
| Return of Mortal Remains: | $20,000 |
| Emergency Reunion: | $10,000 |
| Return of Minor Child(ren): | $5,000 |
| Interruption of Trip: | $5,000 |
| Loss of Checked Luggage: | $250 |
| Local Ambulance Expense: | $2,500 |
| Accidental Death & Dismemberment: | $25,000 Principal Sum for Insured or Insured Spouse, $5,000 for Dependent Child. |
| Hospital Room & Board: | Usual, reasonable and customary to the selected Policy Maximum. |
| Intensive Care: | Usual, reasonable and customary to the selected Policy Maximum. |
| Outpatient Medical Expense: | Usual, reasonable and customary to the selected Policy Maximum. |
| Unexpected Recurrence: | Up to $1000 for those traveling outside the United States and Canada (see exclusion #1). |
| Benefit Period: | Six months |
WHY
INTERNATIONAL MEDICAL INSURANCE?
Each year, millions of people travel outside of their Home Countries,
beyond the boundaries of their medical insurance. They're concerned with the
potential out-of-pocket expenses that could result from an injury or sickness
abroad. Liaison International offers medical coverage and emergency services
to individuals and families traveling outside their Home Countries. This
brochure
is a brief description of Liaison International. For a full description, see
the Program Summary, which will be mailed to you once you are approved for
coverage.
ELIGIBILITY
Liaison International provides coverage as outlined in this brochure
for individuals and families (including unmarried dependent children over 14
days and under 19 years of age) while traveling outside of their home country.
Home Country
is defined as - The country where an insured person(s) has his/her true, fixed
and permanent home and principal establishment.
PERIOD
OF COVERAGE
The minimum
period of coverage under Liaison International is 15 days, maximum is 12 months
(see Continuing Coverage section). Coverage can be purchased in a combination
of monthly and 15 day periods by paying the appropriate plan cost. If you are
traveling for a long period of time, please refer to "Continuing
Coverage"
section.
Expiration Date
Coverage will end on the earlier of the following: 1) The arrival of the Insured
Person back in their Home Country *; or 2) The date shown on the ID Card, for
which plan cost has been paid; *See Home Country Coverage Section.
DESCRIPTION OF COVERAGE
Medical
When the Insured incurs a covered Injury or Illness, the program will pay Usual,
Reasonable and Customary medical charges for Covered Expenses, excess of the
chosen Deductible and Coinsurance, up to the selected Policy Maximum.
Only such expenses, incurred as the result of a disablement, which are
specifically
enumerated in the following list of charges, are incurred within six months
from the onset of an Injury or Illness, and which are not excluded in the
Exclusions,
shall be considered as Covered Expenses:
Dental
- Emergency Only
The Emergency Dental Benefit is only available to programs purchased for 1 month
or more. Treatment necessary to resolve acute, spontaneous and unexpected
inception
of pain to natural teeth ($100) or Dental treatment necessary to restore or
replace sound natural teeth lost or damaged in an Accident which is covered
under the program ($500). This benefit is subject to the Deductible and
Coinsurance.
Emergency Medical Evacuation
/ Repatriation
The Program will pay Covered Expenses incurred if any covered Injury or Illness
commencing during the Period of Coverage results in the Medically Necessary
Emergency Medical Evacuation or Repatriation of the Insured Person (the Insured
Person's medical condition warrants immediate transportation from the medical
facility where the Insured Person is located to the nearest adequate medical
facility where medical treatment can be obtained). The benefit must be ordered
by the Assistance Company in consultation with the Insured Persons local
attending Physician. *
Return of Mortal Remains
The Program will pay the reasonable Covered Expenses incurred up to a maximum
of $20,000 to return the Insured Person's remains to his/her Home Country, if
he or she dies. *
Emergency Medical Reunion
When Emergency Medical Evacuation or Repatriation is ordered and the attending
Physician recommends that a family member travel with the Insured, the program
will arrange and pay, up to $10,000, for round trip economy-class transportation
for one individual selected by the Insured Person, from the Insured
Persons
Home Country to the location where the Insured Person is hospitalized and return
to the Home Country.*
Return of Minor Child(ren)
Should the Insured Person be traveling alone with a Minor Child(ren) and is
hospitalized because of a covered Illness or Injury and the Minor Child(ren),
under age 19, is left unattended, the program will arrange and pay up to $5,000
for one way economy fare to their Home Country (including the cost of an
attendant/escort,
if necessary to insure the safety and welfare of the Minor Child(ren)). *
Hospital Indemnity
If you are hospitalized while traveling outside of the United States or Canada,
and the hospitalization is considered a Covered Expense, the program will
indemnify
the Insured $100 for each night spent in the hospital (this benefit is in
addition
to any other covered expenses of the program).
Interruption
of Trip
If the Insured is unable to continue the Trip due to the death of an Immediate
Family member (parent, spouse, sibling or child) or due to serious damage to
the Insured's principal residence from fire, flood or similar natural disaster
(tornado, earthquake, hurricane, etc.). The program will reimburse the Insured
(up to $5,000)
for the
cost of economy travel, less the value of applied credit from an unused return
travel ticket, to return home to their area of principal residence.*
Loss of Checked Luggage
If the Insured's checked luggage is permanently lost by the airline, the program
will reimburse the Insured for the replacement of clothing and personal hygiene
items lost to a maximum per bag limit of $50 (up to $250). This benefit is
secondary
to any other (including airline) coverage available. The Insured must furnish
proof to the Company that full reimbursement has been obtained from the
airline.*
Assistance Services
Upon enrollment into Liaison International, you are eligible to use any of the
assistance services provided by the Assistance Service Provider. Additional
information is contained in the Program Summary.
Home Country Coverage
This benefit covers you for incidental trips to your Home Country (60 days per
12 months of purchased coverage or pro rata thereof - example: approximately
5 days per month). Maximum benefit is reduced to $50,000 while in your Home
Country. Coverage will be limited to $5,000 for conditions first diagnosed
outside
Your Home Country (Does not apply for Emergency Evacuation or Repatriation).
* NOTE: In the event that an Emergency Medical Evacuation, Repatriation, Return of Mortal Remains, Emergency Reunion, Return of Minor Child(ren), Interruption of Trip, Loss of Checked Luggage benefit is needed or utilized, arrangements must be made by the Assistance Service Provider. Complete details about the benefits and about the required notification of the Assistance Service Provider are contained in the Program Summary.
OPTIONS
Continuing Coverage
For those who are intending longer international trips, an option is available to you. If you choose this option on the application and enroll in at least three (3) months, a notice will be sent to your address of correspondence, allowing you to continue with another period of coverage (minimum of 1 month, maximum of 12 months). If you purchase at least an additional three months, SRI will continue to send notices to your address of correspondence. If you choose to purchase less than three months, SRI will assume that your international trip is complete and will not send any further notices.
While a new period of coverage will be issued, your original effective date will be used with regards to calculating your deductible and coinsurance (for up to a total of 12 months, then they begin again), as well as determining any pre-existing conditions. Since SRI's Benefit Period states that the program will pay up to a total of 6 months for any one eligible condition, you can be protected beyond your period of coverage.
The maximum period of time SRI will offer this option is three years (one year for persons age 70 and over). It is important to note that rates and benefits may change for each subsequent period of coverage. A $5.00 Administrative Fee will be included on each notice. This option is not available if you allow coverage to expire prior to reapplying. If this happens, an entirely new program must be purchased (preexisting condition begins again).
Hazardous
Sport Coverage
To cover motorcycle / motor scooter riding, mountaineering (4500 meter limit),
hang gliding, parachuting, bungee jumping, water skiing, snow skiing,
snowmobiling,
and snow boarding.
PRENOTIFICATION / REFERRAL
In order to ensure your claims are addressed as efficiently as possible, the Insured or the provider of service must contact the Assistance Company for prenotification prior to: any medical treatment in the US as well as hospital admissions and inpatient / outpatient surgeries incurred worldwide. The Assistance Company has trained personnel available 24 hours a day, 7 days a week throughout the year to answer your questions, provide assistance, and guide you to an appropriate facility if necessary. In the case of an Emergency Admission, the Assistance Company must be contacted within 48 hours, or as soon as reasonably possible. Prenotification does not guarantee that benefits will be paid. Failure to prenotify will result in a 20% reduction in Eligible Benefits.
Please be aware that this is not a general health insurance policy, but an interim, limited benefit period, travel medical program intended for use while away from your Home Country. Liaison International does not guarantee payment to a facility or individual for medical expenses until SRI determines that it is an eligible expense.
REFUND
OF PLAN COSTS
Refund of plan costs will be considered only if written request
is received by SRI prior to the Effective Date of Coverage. After the
Effective Date of Coverage, the plan cost is considered fully earned and
nonrefundable.
CLAIM
SUBMISSION
Filing a claim with SRI is easy. You will receive a Liaison International
identification card and claim form once you are approved for insurance. When
you receive treatment, send the original, itemized bills to SRI within 90 days.
Eligible bills are automatically converted from local currencies to US dollars.
For payment of eligible medical expenses, notify SRI of pending treatments and
we can refer you to approved health care providers worldwide. You're only
responsible
for your deductible, coinsurance amounts and non-eligible expenses. For more
details, consult the Program Summary that is provided with your insurance kit,
or contact the SRI Claim Department.
EXCLUSIONS
For Medical benefits, this Insurance does not cover:
* Options are available to include all or part of these risks.
About SRI
Since 1993, Specialty Risk International has provided medical insurance to corporations, international travelers, expatriates, students, overseas visitors, immigrants and global citizens. With expertise and efficiency, we've served clients in more than a hundred countries.
INFORMATION
This Insurance, under Policy HTP01158 is underwritten by: Virginia Surety Company, Inc. Executive Offices: 1000 Milwaukee Avenue, Glenview, IL 60025.
Policy terms and conditions are briefly outlined in this brochure.
Complete provisions pertaining to this insurance are contained in the Master Policy on file with the trustee, American Consumer Insurance Trust, and Liaison International. In the event of any conflict between this brochure and the Master Policy, the Policy will govern. A Program Summary, listing more detailed exclusions, will be mailed to you along with Your ID Card once coverage is purchased.
Notice to Florida residents: the benefits of this policy providing Your coverage are governed by the law of a state other than Florida. Your Homeowners policy, if any, may provide coverage for loss of personal effects provided by the Loss of Checked Luggage coverage. This insurance is not required in connection with the purchase of Your travel arrangements.
ENROLLING IN LIAISON INTERNATIONAL
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Return
the Application with your payment for the total payment to:
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MONTHLY RATES
Effective until December 31, 2002
Rates Based on a $250 Deductible.
Rate for 15 day coverage is 1/2 the monthly rate.
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For
those Traveling to the United States
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For
those Traveling Outside the US
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| *Ages 80+ limited to $15,000. Dep. Child rate is applicable when at least one parent will also be covered under Liaison International. Child Alone rate is used when a child will be insured by themselves. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
INSURANCE
CARRIER
Virginia Surety Company, Inc.
1000 Milwaukee Avenue - Glenview, IL 60025
Rated A+ "Superior" by A.M. Best
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LIAISON International 2002 Application
Effective until December 31, 2002 |
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| OFFICIAL USE ONLY: | Cert#: | Processed: | Eff Date: | Agent: #4269 |
APPLICANT INFORMATION
| Last Name: | |
| First Name: | M.I.: |
| Country of Permanent, fixed Residence (Home Country): | |
| Passport Number / Country: | |
| AD&D Beneficiary: | Relationship: |
ADDRESS OF CORRESPONDENCE - where ID card is to be sent:
| Name: | |
| Address: | |
| City: | State: |
| Postal Code: | Country: |
| Work Phone: ( _____ ) | Home Phone: ( _____ ) |
| Email Address: | |
| Previously insured by SRI? | ID Number: |
| Departure date from your Home Country? (MM/DD/YY) ____ / ____ / ____ | |
| When would you like coverage to begin? (MM/DD/YY) ____ / ____ / ____ | |
| Destination? | Length of Trip? |
| Please note: The minimum period of coverage is 15 days, the maximum is 12 months (please see Continuing Coverage). Coverage must be purchased in increments of no less than 15 days. Coverage cannot begin until your departure from your Home Country, nor will coverage begin until SRI receives and accepts your application and correct payment. | |
COVERAGE SPECIFICS - please check your chosen item
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CALCULATING YOUR PLAN COST for Liaison International 2002 - (Please complete entire section)
| Name of Persons to be Insured: |
Date of
Birth
MM/DD/YY |
Monthly
Rate
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| Applicant: | ||
| Spouse: | ||
| Child: | ||
| Child: | ||
| Child: | ||
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Total: [A] |
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| Multiply [box A] by number of months |
X
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Total:
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$ | |
| If desired, add 15 day rate (1/2 of box A) |
+
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$ |
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Total:
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$ | |
| Multiply by deductible factor: |
X
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Total:
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$ | |
| Multiply Coverage Option Factor: (if applicable) |
X
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Total Payment
Enclosed:
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$ | |
METHOD OF PAYMENT - please check your payment method
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| Card Number: | ||||||
| Expiration Date: | Day Phone Number: | |||||
| Name on Card: | ||||||
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Billing
Address
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| Signature (Required): | ||||||
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Make Check or Money Order payable to "SRI". Total payment for the Full Term of coverage requested must be paid in US dollars at the time application for coverage is made. Coverage purchased by credit card is subject to validation and acceptance by the credit card company. I declare that I understand the terms and conditions of this product, as outlined in this brochure. I understand that preexisting conditions, as defined in Exclusion number 1, are excluded. I understand this program is for persons traveling outside their home country. I hereby subscribe to the American Consumer Insurance Trust and enroll in the group coverage for which I am eligible under the group contract issued by Virginia Surety Company, Inc.
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Liaison® is a registered
Trademark of Specialty Risk International, Inc.
In Florida, Florida Resident - Agent No. A10702