Seven Corners Visitor Insurance

ELIGIBILITY

who can buy inbound® immigrant?

You are eligible for coverage if you are a non-United States citizen traveling to the U.S. for business, pleasure, to study, or to immigrate. Your coverage must become effective within 24 months of your arrival in the United States.

It is your responsibility to maintain all records regarding travel history and age and provide necessary documents to Seven Corners to verify eligibility if required.

length of coverage

Your coverage length may vary from 5 days to a maximum of 364 days in a policy period. Your total period of coverage cannot exceed 1,820 days (five 364-day policy periods). You have the option to renew coverage in any increment of 5 days or more (there is a $5 fee each time you renew). If you allow coverage to lapse, you must return to your home country for a minimum of 31 days before reapplying.

coverage start date - Coverage will not begin until you leave your home country, and we receive your application and premium. This is your effective date.

coverage expiration date - Your coverage ends at 12:01 A.M. North American Eastern Time on the earlier of the following: the expiration date on your ID card; the 31st day of your return trip to your home

1 country; after completion of 1,820 days of coverage (approximately 5 years); the day you become a U.S. citizen; the date you enter active military service.

your visitor and travel insurance company

Inbound® Immigrant is underwritten by Certain Underwriters at Lloyd’s of London and is rated “A” (Excellent) by A.M. Best. In addition to being one of the largest travel insurance entities in the world, Lloyd’s has over 300 years of experience in the international visitors insurance business.

Seven Corners, your program administrator

Seven Corners* has administered Inbound® Immigrant since inception. We have provided medical and travel and visitors insurance to corporations, international travelers, expatriates, students, overseas visitors, immigrants and global citizens for 20 years. Seven Corners Assist, our multilingual 24-hour assistance team, is here to answer questions. You may see any provider of your choice. Contact information for Seven Corners Assist is on your ID card.

*In California, operating under the name Seven Corners Insurance Services.

ELIGIBILITY

your benefits

medical benefits - If your covered injury or sickness requires medical treatment, we will pay the coverage amounts listed in the schedule of benefits, minus your chosen per person deductible.

Treatment must be received within 364 days of the injury or sickness (224 days if you are 70 & over).

incidental trips to your country - We will pay up to $50,000 for an illness or injury which occurs while you are on an incidental trip to your home country (30 days per 364 days of purchased coverage or pro rata thereof, approximately 2½ days per month).

international travel coverage - If you buy at least 30 days of coverage, you may travel to countries other than the United States for up to 30 days. This benefit does not include travel back to your home country, and it does not extend after your current expiration date.

emergency medical evacuation* - We will pay up to $10,000 for a medical evacuation, if your medical condition requires immediate transportation from your current medical facility to the closest facility with appropriate care. A legally licensed physician must recommend the evacuation.

return of mortal remains* - We will pay up to $7,500 for preparation and return of your remains to your country of residence. 2

*Arrangements for evacuation & return of remains must be made by Seven Corners Assist.

common carrier accidental death & dismemberment (ad&d)

This benefit pays up to $25,000 for accidents occurring while you are riding as a passenger in or on any land, water or air conveyance transporting passengers for hire. Your loss must occur within 365 days after the accident date. A description of the covered losses is shown below:

For Loss of:	Indemnity:
Life	Principal Sum
Both Hands or Both Feet or Sight of
Both Eyes	Principal Sum
One Hand and One Foot	Principal Sum
Either Hand or Foot and
Sight of One Eye	Principal Sum
Either Hand or Foot	One-Half the Principal Sum
Sight of One Eye	One-Half the Principal Sum

DESCRIPTION OF COVERAGE

refund of premium

We realize there is uncertainty in international travel. Refund of total plan cost will be considered only if a written request is received by Seven Corners prior to your effective date of coverage. If the request is received after your effective date, the unused portion of the plan cost may be refunded minus a cancellation fee, provided you have not submitted a claim.

important terms

pre-existing condition means any medical condition, sickness, injury, illness, disease, mental illness or mental nervous disorder, regardless of the cause, including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting therefrom, that with reasonable medical certainty existed at the time of application or within the 180 days (365 days if 70 & older) immediately prior to your effective date whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to 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 180 days (365 days if 70 & older) immediately preceding your effective date of coverage.

5 acute onset of a pre-existing condition means a sudden and unexpected outbreak or recurrence of a pre-existing condition which occurs spontaneously and without advance warning either in the form of physician recommendations or symptoms and is of short duration, rapidly progressive, and requires urgent care. The acute onset must occur after the effective date of the policy, and treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A pre-existing condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered an acute onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or treatment existent or necessary prior to your

effective date of coverage.

home country means the country where your passport was issued.

exclusions

The list below is a summary of the exclusions in the certificate. This brochure is intended as a brief summary of benefits and services and is not your policy. A complete description of the provisions, benefits, and exclusions are contained in the program summary which you may view online. You will receive this document when your coverage is issued. If there is any difference between this brochure and your program summary, the provisions of the certificate will prevail.

No benefits will be paid for loss or expense caused by, contributed to, or resulting from:

•Pre-existing Conditions as defined herein. If you are a non-U.S. citizen

EXCLUSIONS AND LIMITATIONS

exclusions (cont.)

under age 70, this exclusion is waived for an Acute Onset of a Pre- existing Condition (defined above) as shown in the schedule of benefits for your plan (A or B). Benefits will be paid for expenses incurred in the U.S., minus your deductible and subject to the scheduled limits. All other exclusions apply.

•Any loss occuring while traveling solely for medical treatment, while on a waiting list for treatment, or while traveling against the advice of a Physician; expenses which are not medically necessary;

•The maximum benefit is $50,000 for any illness/injury occurring while on an incidental trip to your home country;

•Routine physicals, inoculations, exams with no objective indications of impairment of normal health; well-baby care; routine newborn baby care, well-baby nursery;

•Eye exams & treatment of visual defects; glasses; contact lenses.

•Hearing exams; hearing aids; treatment for hearing defects;

•Dental treatment unless due to injury to sound, natural teeth;

•Weak, strained or flat feet, corns, calluses, or toenails;

•Cosmetic surgery, or treatment for congenital anomalies (except as specifically provided), except reconstructive surgery due to a covered injury or sickness; Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered injury/ sickness;

•Elective surgery and elective treatment;

•Treatment, drugs, diagnostic or surgical procedures for infertility, impotency, artificial insemination, sterilization or reversal thereof, unless infertility is a result of a covered injury/sickness;

•Birth control, including surgical procedures and devices;

•Injury while participating in professional, sponsored, and/or organized amateur or intercollegiate athletics;

•Injury while taking part in mountaineering, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or

motorcycle, snowmobiling, motorcycle/motor scooter riding (as a

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passenger or driver), scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, wakeboard riding, jet skiing, windsurfing, snow skiing & snowboarding;

•Injury or sickness where benefits are payable under Worker’s Compensation or an Occupational Disease Law or Act;

•Organ and tissue transplants and related services and supplies;

•Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war; terrorist activity; nuclear, chemical, or biological weapons of mass destruction; (additional details in the program summary);

•Suicide or attempted suicide (including drug overdose), while sane or insane; intentionally self-inflicted Injury;

•Charges of an institution, health service, or infirmary which does not require payment in the absence of insurance;

•Treatment of nervous or mental disorders; treatment of alcohol, chemical, or drug addiction, dependency, use or abuse, including illness caused by such use; injuries related to alcohol, chemicals or drugs unless prescribed by a Physician, except as stated in the schedule of benefits for mental and nervous disorders;

•Loss from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;

•Treatment, services, supplies in a hospital owned/operated by: a) The Veteran’s Administration; or b) A national government or its agencies.

(This exclusion does not apply to treatment you are required by law to pay);

•Duplicate services of a certified nurse-midwife & physician;

•Expenses payable under any prior policy in force for the person making the claim; expense covered by any other valid & collectible medical, health or accident insurance;

•A hospital emergency room visit not of an emergency nature;

•Outpatient treatment for the detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;

EXCLUSIONS AND LIMITATIONS

exclusions (cont.)

		•	Injury due to you operating a motor vehicle while not properly
			licensed to do so;
		•	Voluntary or elective abortion;
		•	Expense incurred after this insurance terminates except as may be
			specifically provided;
		•	Sexually transmitted and venereal diseases;
		•	Treatment incurred by you if you were HIV Positive at the time
			of application for this insurance, whether or not you were
			asymptomatic or symptomatic or had knowledge of your HIV
			status on your effective date or any associated diagnostic tests
			or charges for HIV infection, seropositivity to the AIDS virus, AIDS
			related Illness(es), ARC Syndrome, AIDS, and all diseases caused by
			&/or related to HIV;
		•	Treatment for HIV, the AIDS virus, AIDS related Illness, ARC Syndrome,
			AIDS, & all diseases & illnesses caused by &/or related to HIV or arising
			as complications from these conditions including the cost of testing
			for these conditions &/or charges for drug treatment or surgeries;
		•	Treatment for tuberculosis, malaria, cholera, dengue fever and
			parasitic-sourced illnesses, including treatment required as a
			result of complications from those same diseases, whether or not
			previously manifested or symptomatic prior to your effective date;
		•	Expenses which are experimental/investigational or for research
			purposes; vocational, speech, recreational or music therapy; durable
			medical equipment;
		•	Chiropractic care or complementary medicine including
			acupuncture and massage;
		•	Services/supplies provided by your relative or anyone living with
			you;
		•	Treatment of the temporomandibular joint;
		•	Treatment required as a result of complications or consequences of
			a treatment or for a condition not covered under this policy;
	7	•	Expenses for home health care, custodial care and/or daily living;
		•	Expenses for environmental supplies, including handrails, ramps,

special telephones, air conditioners, home delivered meals.

important information

The information concerning Inbound® Immigrant is not intended to be an offer to sell Inbound® Immigrant or a solicitation by Seven Corners, Inc. or Lloyd’s of London in any jurisdiction where any such sale would be unlawful or in which Seven Corners or Lloyd’s of London are not qualified to do so.

Please be aware that this is not a general health insurance policy, but an interim program intended for temporary use. We do not guarantee payment to a facility or individual for medical expenses until we determine it is an eligible expense.

proof of your coverage

When you purchase coverage on Inbound® Immigrant, you will receive an email from Seven Corners. This will include your virtual ID card and a link to the program summary. This is the legal document which describes the benefits and provisions of the plan in detail.

claim submission

Filing a claim with us is easy. When you receive treatment, send the itemized bills to Seven Corners within 90 days via e-mail, fax, or postal mail along with a completed Proof of Loss form (available online).

PROGRAM COST

Rates Effective February 1, 2013

Premiums for Ages 69 and Younger

$75 per injury/sickness deductible per person
Policy Maximum Options	Plan A	Plan B
Age	$50,000	$100,000
	Monthly/Daily	Monthly/Daily
2 weeks to 18	$65 / $2.17	$95 / $3.17
19 to 29	$52 / $1.74	$76 / $2.54
30 to 39	$59 / $1.97	$86 / $2.87
40 to 49	$65 / $2.17	$95 / $3.17
50 to 59	$98 / $3.27	$138 / $4.60
60 to 69	$103 / $3.44	$145 / $4.84
Dependent Child	$62/ $2.06	$90 / $3.01
$150 per injury/sickness deductible per person
Policy Maximum Options	Plan A	Plan B
Age	$50,000	$100,000
	Monthly/Daily	Monthly/Daily
2 weeks to 18	$62 / $2.07	$91 / $3.04
19 to 29	$50 / $1.67	$73 / $2.44
30 to 39	$56 / $1.87	$82 / $2.74
40 to 49	$62 / $2.07	$91 / $3.04
50 to 59	$95 / $3.17	$135 / $4.50
60 to 69	$100 / $3.34	$142 / $4.74
Dependent Child	$59 / $1.97	$87 / $2.89

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*Dependent Child (Ages 2 weeks to 18) rate is applicable when at least one parent will also be covered under Inbound® Immigrant.

Premiums for Ages 70 and Older

$125 per injury/sickness deductible per person

Policy Maximum Options

Age	$50,000
Monthly/Daily	Monthly/Daily
Age 70 to 74	$118 / $3.94
Age 75 to 79	$122 / $4.07
Age 80 to 84	$158 / $5.27
Age 85 to 89	$166 / $5.54
Age 90 to 94	$175 / $5.84
Age 95 to 99	$183 / $6.10

$250 per injury/sickness deductible per person

Policy Maximum Options

Age	$50,000
	Monthly/Daily
Age 70 to 74	$108 / $3.60
Age 75 to 79	$111	/ $3.70
Age 80 to 84	$144	/ $4.80
Age 85 to 89	$151	/ $5.04
Age 90 to 94	$159	/ $5.30
Age 95 to 99	$167 / $5.57

[pull-out application form]

Effective February 1, 2013

Date of Birth							Monthly	Daily
MM/DD/YY							Rate	Rate
	/			/
	/			/
	/			/
	/			/
	/			/
Total:							$	$

AD&D Beneficiary: Relationship:

passport & travel information:

Passport Number: Country Issuing Passport:

When did or will you arrive in the United States?

(MM/DD/YYYY) / /

Date you would like coverage to begin:

(MM/DD/YYYY) / /

Note: This program is not available to United States citizens. Your coverage must begin within 24 months of your arrival in the United States. The minimum period of coverage is 5 days, maximum is 364 days . An automatic renewal notice will be sent to the email address listed above. Total program length available is 1,820 days (approximately 60 months). Coverage cannot begin until you depart from your home country and Seven Corners both receives and accepts your application and correct premium.

coverage specifics

Have you purchased visitors insurance through Seven Corners before?

qNo	qYes If Yes, ID Number:
Selected Medical Policy Maximum:
qPlan A: $50,000		qPlan B: $100,000
Selected Per Injury/Sickness Deductible:
q$75	q$150		70 and over : q$125 q$250

If there are applicants below age 70 and applicants age 70 and above, separate applications must be submitted.

Complete and return the Application with your payment to:

303 Congressional Boulevard, Carmel, IN 46032

Fax: 317-575-2659 Phone: 800-335-0611 or 317-575-2652 Online: www.sevencorners.com

(You may fax your application only if paying by credit card. Originals are not required if application is faxed to Seven Corners with credit card payment.)

Attention Applicants: Certain Underwriters at Lloyd’s of London, operates as an approved Surplus Lines market in the United States. The premiums listed include a general Surplus Lines Tax. Your State of Residence may warrant an additional Surplus Lines Tax, Stamping Fees and administration fee. Upon receipt and review of your application, Seven Corners will inform you if additional taxes and fees apply. If so, Seven Corners will request the payment of the additional taxes and fees from you prior to issuing coverage. The additional Surplus Lines Taxes and fees will be listed on the declaration page of your policy.

Multiply Monthly Rate Total by number of months:	x
Monthly Total [A]:		$
Multiply Daily Rate Total by number of days:	x
	Daily Total [B]:	$
Administrative Fee ($5.00 - Required):	+	$5.00
Total Payment Enclosed:		$

method of payment

qCheck	qMoney Order						qMasterCard	q Visa
qDiscover qAmerican Express
Card Number:
Expiration Date:							Daytime Phone: (	)
Name on Card:
Billing Address:
Signature (Required)

Make Check or Money Order Payable to: “Seven Corners”. Total Payment for the Full Term of coverage requested on this application must be paid in U.S. Dollars (checks must be issued from a

U.S. bank) 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 agree to and have read and understand the terms and conditions of this product as outlined in this brochure and the program summary. I also understand that coverage is not available to any U.S. citizen. I understand that pre-existing conditions, as defined in the program summary, are not covered. I understand this is not a general health insurance product but a limited benefit program designed to provide basic benefits under certain circumstances.

I hereby subscribe to the Global International Trust and enroll in the group coverage for which I am

eligible under the group contract issued by Certain Underwriters at Lloyd’s of London.

As signatory, I declare that I am affirming all statements for all persons listed on the application (and declare that I have the authority to do so).

Patient Protection and Affordable Care Act: 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”). The insurance benefits provided by this policy are stated in your policy documents and do not include additional benefits required by PPACA. The PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney, insurance agent or tax professional to determine if the PPACA’s requirements are applicable to you.

Signature of Insured or Proxy (Required)

Date