ELIGIBILITY

who can buy Inbound® usa?

You are eligible for coverage if you are a non-United States citizen traveling to the U.S. for business, pleasure, or to study. Your coverage must become effective within 12 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 364 days. You have the option to renew coverage in whatever increment you choose subject to a 5 day minimum (there is a $5 fee each time you renew). You may apply for a new period of coverage after 364 days if you return to your home country before doing so.

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 AM North American Eastern Time on the earlier of the following: the date you return to your home country; 364 days after your effective date; the expiration date on your ID card; the day you become a U.S. citizen or enter into active military service.

1

your visitors insurance company

Inbound® USA 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 and visitor insurance entities in the world, Lloyd’s has over 300 years of experience in the international travel insurance business.

Seven Corners, your program administrator

Seven Corners* has administered Inbound® USA since inception. We have provided medical and travel 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.

your benefits

medical benefits - If your covered injury or sickness requires medical treatment, we will pay the coverage amounts in the schedule of benefits, minus your chosen per person deductible. Please note that treatment for your injury or sickness must be received within 26 weeks of your injury or sickness.

DESCRIPTION OF COVERAGE

your benefits (cont.)

international travel coverage - If you purchase 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 $50,000 for an emergency medical evacuation, if your medical condition requires immediate transportation from your current medical facility to the closest facility with appropriate care. This benefit must be ordered by Seven Corners Assist in consultation with your attending Physician. *

return of mortal remains* - We will pay up to $7,500 to return your remains to your home country.*

*Arrangements for emergency medical evacuation and return of mortal 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		2
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

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

DESCRIPTION OF COVERAGE

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.

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, is 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 you have your true, fixed and permanent home and principal establishment.

exclusions

The list below is a summary of the exclusions in the certificate. This 7 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. If you are a non-U.S. citizen 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, B, C, or D). Benefits will be provided for expenses incurred in the U.S., minus your deductible and subject to the scheduled limits. All other exclusions apply.

•Travel solely for medical treatment; travel against a Physician’s advice;

•Expenses which are not medically necessary;

•Expenses incurred in your home country or country of regular domicile;

•Routine physicals, inoculations, well-baby care & nursery, new-born baby care; related Physician charges;

•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;

•Services or supplies provided by a family member or anyone living with you;

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

• Cosmetic surgery, treatment for congenital anomalies (except as specifically provided), except reconstructive surgery due to a covered injury or sickness;

•Elective surgery & elective treatment;

•Treatment to promote conception or prevent conception & childbirth;

EXCLUSIONS AND LIMITATIONS

exclusions (cont.)

•Injury while participating in professional, sponsored &/or organized amateur or interscholastic athletics;

•Organ transplants;

•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; (details in program summary);

•Participation in a riot or civil disorder, commission of or attempt to commit a felony;

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

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

•Treatment of nervous or mental disorders, except as stated in the schedule of benefits; treatment of alcoholism or drug abuse, except as provided for treatment of mental/nervous disorders, according to the schedule of benefits;

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

•Treatment, services, or 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 and Physician;

•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 sublimation in the human body for purposes of removing nerve

	interference & the effects thereof, where such interference is the	8
	result of or related to distortion, misalignment or subluxation of or
	in the vertebral column;

•Injury while taking part in mountaineering where ropes or guides are normally used, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle, motorcycle/motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing, snow boarding and snowmobiling;

•Treatment paid for or furnished under any other individual, government, or group policy; previous policy; Worker’s Compensation or Occupational Disease Law or Act; charges provided at no cost to you;

•Expense incurred after your expiration date except as may be specifically provided;

•Treatment for alcohol & drug addiction; use of drugs or narcotic agents; injury/sickness due to the effects of intoxicating liquor or drugs, unless prescribed by a physician;

•Sexually transmitted diseases;

•Pregnancy expenses or sickness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from injury; or voluntary or elective abortion;

EXCLUSIONS AND LIMITATIONS

exclusions (cont.)

•Custodial care, educational or rehabilitative care & nursing services in a long term facility, spa, hydroclinic, weight loss clinic, sanatorium, nursing home or similar facilities;

•Speech therapy, occupational therapy, vocational rehabilitation;

•Treatment if you are 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 Illnesses, ARC Syndrome, AIDS, & all diseases caused by &/or related to HIV;

•Treatment for HIV, the AIDS virus, AIDS related illnesses, ARC Syndrome, AIDS, & all diseases & illnesses caused by &/or related to HIV or complications from these conditions, including the cost of testing for these conditions &/or charges for treatment.

important information

The information concerning Inbound® USA is not intended to be an offer to sell Inbound® USA or a solicitation by Seven Corners 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. Inbound® USA does not guarantee payment to a facility or indi- vidual for medical expenses until we determine it is an eligible

expense.

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proof of your coverage

When you purchase coverage on Inbound® USA, 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). Contact information is provided in your program summary. Please retain your original bills should there be a need for verification. Eligible bills are automatically converted from local currencies to U.S. dollars. For more details, contact the Seven Corners Claim Department.

PLAN COST

	Rates Effective February 1, 2013
	$0 Per Injury / Sickness Deductible Per Person
	Policy Maximum Options
		Plan A	Plan B	Plan C	Plan D
	Age	$50,000	$75,000	$100,000	$130,000
		Monthly/Daily	Monthly/Daily	Monthly/Daily	Monthly/Daily
	2 weeks - 18	$45 / $1.51	$53 / $1.78	$61 / $2.04	$80 / $2.65
	19 - 29	$38 / $1.25	$44 / $1.46	$51 / $1.68	$66 / $2.18
	30 – 39	$42 / $1.40	$50 / $1.65	$57 / $1.89	$74 / $2.46
	40 - 49	$45 / $1.51	$53 / $1.78	$61 / $2.04	$80 / $2.65
	50 – 59	$62 / $2.06	$72 / $2.39	$82 / $2.73	$106/ $3.54
	60 – 69	$69 / $2.29	$80 / $2.66	$91 / $3.03	$118 / $3.94
	Dependent Child*	$43 / $1.43	$51 / $1.69	$58 / $1.94	$76 / $2.52
	$50 Per Injury / Sickness Deductible Per Person
	Policy Maximum Options
		Plan A	Plan B	Plan C	Plan D
	Age	$50,000	$75,000	$100,000	$130,000
		Monthly/Daily	Monthly/Daily	Monthly/Daily	Monthly/Daily
	2 weeks - 18	$38 / $1.26	$44 / $1.47	$51 / $1.69	$66 / $2.19
	19 – 29	$31 / $1.04	$37 / $1.22	$42 / $1.39	$54 / $1.81
	30 – 39	$35 / $1.17	$41 / $1.37	$47 / $1.57	$61 / $2.03
	40 – 49	$38 / $1.26	$44 / $1.47	$51 / $1.69	$66 / $2.19
	50 – 59	$52 / $1.72	$60 / $2.00	$68 / $2.28	$89 / $2.96
	60 – 69	$57 / $1.91	$67 / $2.22	$76 / $2.53	$99 / $3.29
	Dependent Child*	$36 / $1.20	$42 / $1.40	$48 / $1.61	$62 / $2.08
	$100 Per Injury / Sickness Deductible Per Person
	Policy Maximum Options
		Plan A	Plan B	Plan C	Plan D
	Age	$50,000	$75,000	$100,000	$130,000
		Monthly/Daily	Monthly/Daily	Monthly/Daily	Monthly/Daily	10
	2 weeks – 18	$35 / $1.16	$41 / $1.37	$47 / $1.57	$62 / $2.05
	19 - 29	$29 / $0.96	$34 / $1.13	$39 / $1.30	$51 / $1.69
	30 - 39	$32 / $1.08	$38 / $1.27	$44 / $1.46	$57 / $1.90
	40 - 49	$35 / $1.16	$41 / $1.37	$47 / $1.57	$62 / $2.05
	50 – 59	$48 / $1.59	$57 / $1.90	$67 / $2.22	$86 / $2.88
	60 – 69	$53 / $1.78	$64 / $2.12	$74 / $2.47	$96 / $3.21
	Dependent Child*	$33 / $1.10	$39 / $1.30	$45 / $1.49	$59 / $1.95

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

Monthly/Daily Premiums for Ages 70 and Older $100 Per Injury / Sickness Deductible Per Person Policy Maximum Options

	Plan J	Plan K
Age	$50,000	$70,000
	Monthly/Daily	Monthly/Daily
Age 70 – 74	$89 / $2.98	$125 / $4.16
Age 75 – 79	$98 / $3.28	$137 / $4.58
Age 80 – 84	$198 / $6.60	$278/ $9.26
Age 85 – 89	$286/ $9.52	$400 / $13.33
Age 90 – 94	$309 / $10.30	$433/ $14.43
Age 95 – 99	$356 / $11.84	$497 / $16.56

$200 Per Injury / Sickness Deductible Per Person

Policy Maximum Options

	Plan J	Plan K
Age	$50,000	$70,000
	Monthly/Daily	Monthly/Daily
Age 70 – 74	$74 / $2.48	$104 / $3.47
Age 75 – 79	$82 / $2.73	$115 / $3.82
Age 80 – 84	$166/ $5.51	$232 / $7.71
Age 85 – 89	$244 / $8.11	$341 / $11.36
Age 90 – 94	$264 / $8.78	$369 / $12.29
Age 95 – 99	$303 / $10.08	$424 / $14.11

INBOUND® USA APPLICATION

(please print or type using black ink)

Official Use Only:
	Cert#:	Processed:
applicant information
qMr. qMrs. qMiss		qMs
Last Name:
First Name:			M.I.

Country of Permanent, fixed Residence (Home Country)

Passport Number:

Passport Country:

for accidental death & dismemberment benefit

Beneficiary: Relationship:

us address of correspondence (address must be in the United States)

Name:

Address:

City:

State:

Postal Code:

Work Phone: ( )

Home Phone: (

)

Email Address:

When did or will you arrive in the United States:

/

/

(MM/DD/YY)

Date you would like coverage to begin:

/

/

(MM/DD/YY)

Note: This program is not available to United States citizens. Your coverage must begin within 12 months of your arrival in the United States. The minimum period of coverage is 5 days, maximum is 364 days. Total

program length available is 364 days. 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 insurance through Seven Corners before? qNo qYes If Yes, ID Number:

Age 2 weeks to Age 69:	Age 70 to 99:
qPlan A: $50,000	qPlan J: $50,000
qPlan B: $75,000	qPlan K: $70,000
qPlan C: $100,000
qPlan D: $130,000

Selected Per Injury/Sickness Deductible:

q$0 q$50 q$100 q$200 (Age 70 and over are only eligible for $100 and $200)

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..

[pull-out application form]

Effective February 1, 2013

Eff. Date:

Agent: 10781

calculating your plan cost (please complete entire section)

Date of Birth

Monthly Rate

Daily Rate

(MM/DD/YY)

Applicant:

(__/__/__)

Spouse:

(__/__/__)

Child:

(__/__/__)

Child:

(__/__/__)

Child:

(__/__/__)

Total:

$

$

Minimum period of coverage is 5 days

Multiply Monthly Rate Total by number of months:

X

Monthly Total [A]:

$

Multiply Daily Rate Total by number of days:

X

Daily Total [B]:

$

Total Payment Enclosed (Total of [A] and [B]):

$

method of payment

qCheck

qMoney Order

qMasterCard

q Visa

qDiscover

qAmerican Express

Card Number:

Expiration Date:

Daytime Phone: (

)

Name as it appears on Card:

Signature (Required)

Billing Address:

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 at the time application for coverage is made. Coverage purchased by credit card is subject to validation and acceptance by 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, including 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 that this is not a general health and visitor insurance product, but a limited benefit program designed to provide basic benefits under certain circumstances. I also understand that Lloyd’s operates as an approved but non-admitted insurer in most US states and that claims may not be made against any state guarantee fund. I understand and agree that this program does not comply with any US state insurance law. I also understand any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an enrollment form, or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

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, 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 . The visitor 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