schedule of coverage

All coverages and plan costs listed in this brochure are in U.S. Dollar amounts.

medical maximum: $50,000; $150,000; $300,000; $500,000 (ages 80+, maximum limited to $15,000)

deductible: $0; $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 Policy Period (see Continuing Coverage)

coinsurance: inside the united states: After you pay the deductible, the program pays 80% of the next $5,000 of eligible expenses, then 100% to the selected Medical Maximum.

outside the united states: After you pay the deductible, the program pays 100% to the selected Medical Maximum.

hospital indemnity: $150 / night (for U.S. citizens traveling outside the United States) in addition to any other Covered Expense.

dental (emergency): $100 ($500 for accidents) Only available to programs purchased for one (1) month or more.

emergency medical evacuation/ repatriation: $300,000 (in addition to the Medical Maximum)

home country coverage: Incidental Trips to The Home Country: $50,000 follow me home coverage: $5,000

1return of mortal remains: $50,000 emergency reunion: $50,000

return of minor child(ren): $50,000 interruption of trip: $5,000

loss of checked luggage: $250 local ambulance expense: $5,000

accidental death & dismemberment (ad&d): $25,000 Principal Sum for Insured or Insured Spouse, $5,000 for Dependent Child(ren).

common carrier accidental death: $50,000 per adult, $25,000 per child(ren) under age of 18; $250,000 Maximum per family

hospital room & board: Usual, reasonable and customary to the selected Medical Maximum

intensive care: Usual, reasonable and customary to the selected Medical Maximum

outpatient medical expenses: Usual, reasonable and customary to the selected Medical Maximum

terrorism: Usual, reasonable and customary to the selected Medical Maximum

waiver of pre-existing conditions: Up to $20,000 for U.S. citizens traveling outside the United States (refer to exclusion #1 for details)

why choose seven corners?

value

Seven Corners utilizes widely recognized and reputable insurance organizations to underwrite our programs. We realize that the value of an insurance program is in the professionalism of the underlying organization. Seven Corners continually invests in its people, systems, and solutions to make the insurance buying experience a favorable one for our clientele.

convenience

Our program brochures and documentation offer a detailed description of the product and underlying coverage.

doctors & hospitals worldwide

Seven Corners has access to over 12,000 doctors and hospitals worldwide. With one phone call, we can assist you in locating a provider. Seven Corners’ Assist is trained to help you locate appropriate care.

why worldwide medical insurance?

2

Each year, millions of people travel beyond the boundaries of their medical insurance. If you are concerned with the potential out-of-pocket expenses that could result from an Injury or Illness while traveling, Liaison® Worldwide offers medical coverage and emergency services to individuals and families traveling outside their Home Country. This brochure is a brief description of Liaison® Worldwide. For a full description, please visit our website at www.sevencorners.com. After you have purchased the program a complete Program Summary will be mailed to you.

eligibility

Liaison® Worldwide provides coverage, as outlined in this brochure, for individuals and families (including unmarried dependent child(ren) over 14 days and under 19 years of age) while traveling outside of their Home Country. Coverage is not

available in all Countries. Please refer to the Information Section of this brochure for a listing of these Countries.

Home Country is defined as - The country where a covered person(s) has his/her true, fixed and permanent home and principal establishment.

description of coverage

period of coverage

The minimum period of coverage under Liaison® Worldwide is five (5) days, maximum is twelve (12) months (see Continuing

Coverage section). Coverage can be purchased in a combination of monthly and/or daily periods by paying the appropriate plan cost. If you are traveling for a long period of time, please refer to “Continuing Coverage” section.

effective date

Your coverage will begin on the latest of the following: 1) The moment you depart your Home Country; or 2) The date and time the Application and full plan cost is received and accepted by Seven Corners; or 3) The date requested on the Application.

expiration date

Coverage will end on the earlier of the following: 1) Your return to your Home Country (except as provided under the Home Country Coverage); or 2) The date shown on the ID Card, for which plan cost has been paid; 3) The date you are no longer eligible under this plan.

3 medical

When you incur 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 Medical Maximum. Only such expenses, incurred as the result of an Injury or Illness, which are specifically enumerated in the following list of charges, are incurred within six (6) months from the onset of an Injury or Illness, and which are not excluded in the Exclusions, shall be considered as Covered Expenses:

1.Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service (with the exception of personal services of a non-medical nature); charges made for an operating room.

2.Charges made for Intensive Care or Coronary Care charges and nursing services.

3.Charges made for diagnosis, treatment and Surgery by a Physician; charges made for the cost and administration of anesthetics.

4.Charges made for Outpatient treatment, same as any other treatment covered on an Inpatient basis. This includes ambulatory Surgical centers, Physicians’ Outpatient visits/examinations, clinic care, and Surgical opinion consultations.

medical (cont.)

5.Charges for medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood transfusions, iron lungs, and medical treatment; dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physician or Surgeon.

6.Charges for physiotherapy, if recommended by a Physician for the treatment of a specific Disablement and administered by a licensed physiotherapist.

7.Ground ambulance (within the metropolitan area) to and from the nearest Hospital with facilities for required treatment. If the covered person is in a rural area and unreachable by ground ambulance, then licensed air ambulance transportation to the

nearest metropolitan area shall be considered a Covered Expense.

dental - emergency only

The Emergency Dental Benefit is available to you provided you have purchased one (1) or more months of coverage. Treatment necessary to resolve acute, spontaneous and unexpected inception of pain to sound 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 4 ($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 commences during the Period of Coverage that results in a Medically Necessary Emergency Medical Evacuation or Repatriation (your medical condition warrants immediate transportation from the medical facility where you are located to the nearest adequate medical facility where medical treatment can be obtained). This benefit must be arranged by the Assistance Company in consultation with the local attending Physician.*

description of coverage

return of mortal remains

The Program will pay the reasonable Covered Expenses incurred up to a maximum of $50,000 to return your remains to your Home Country, if you should die.*

emergency medical reunion

When Emergency Medical Evacuation or Repatriation is arranged and the attending Physician recommends that a family member travel with you, the program will arrange and pay, up to $50,000, for round-trip economy-class transportation for one individual of your choice, from your Home Country, to be at your side while you are hospitalized and then accompany you during your return to your Home Country.

return of minor child(ren)

If you are traveling alone with a Minor Child(ren) and are 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 $50,000 for one-way economy fare to

5 their Home Country (including the cost of an attendant/escort, if necessary to insure the safety and welfare of a Minor Child(ren)).*

hospital indemnity

If you are a U.S. Citizen and are hospitalized while traveling outside of the United States, and the hospitalization is considered a Covered Expense, the program will indemnify you $150 for each night spent in the hospital (this benefit is in addition to any other covered expenses of the program).

interruption of trip

If you are 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 your principal residence from fire, flood or similar natural disaster (tornado, earthquake, hurricane, etc.). The program will reimburse you (up to $5,000) for the cost of economy travel, less the value of applied credit from an unused return travel ticket, to return you home to your area of principal residence.*

loss of checked luggage

If your checked luggage is permanently lost by the airline, the program will reimburse you 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. You must furnish proof to the Company that full reimbursement has been obtained from the airline.

assistance services

Upon enrollment into Liaison® Worldwide, you are eligible to use any of the assistance services provided by the Assistance Services Provider. Additional information is contained in the Program Summary.

•Open 24 hours / day, 365 days a year

•Multilingual personnel

•Physicians / nurses on staff

•Locate local facilities

•Help with emergency situations

home country coverage	6

Incidental Trips to Your Home Country: 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 of purchased coverage). Maximum benefit is reduced to $50,000 for any Illness or Injury occurring while on an incidental trip to your Home Country.

Follow Me Home Coverage: This plan shall pay for Covered Expenses incurred in your Home Country up to $5,000 for conditions that are first diagnosed and treated outside Your Home Country (Does not apply for Emergency Medical Evacuation or Repatriation).

*NOTE: In the event of Emergency Medical Evacuation, Repatriation, Return of Mortal Remains, Emergency Reunion, Return of Minor Child(ren) or Interruption of Trip benefit is needed or utilized, all 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.

description of coverage

options

continuing coverage

For those who are intending longer worldwide trips, an option is available to you. If you choose this option on the application and enroll for at least three (3) months of coverage, a notice will be sent to your address of correspondence, allowing you to purchase an additional

period of coverage (minimum of one (1) month, maximum of twelve (12) months). If you purchase at least three (3) months of coverage, Seven Corners will continue to send notices to your address of correspondence. If you choose to purchase less than three months of coverage, Seven Corners will assume that your worldwide trip is complete and will not send any further notices.

The maximum period of time Seven Corners will offer this feature is three years (one year for persons age 65 and over). It is important to note that rates and benefits may change for each subsequent period of coverage. A $5.00 Administrative

7 Fee will be included on each notice.

Continuing Coverage is available in periods as short as five (5) days at a time when purchased using Seven Corners’ online system.

hazardous sport coverage

To cover motorcycle/motor scooter riding, hang gliding, parachuting, bungee jumping, water skiing, snow skiing, snowmobiling and snow boarding.

Parachuting shall mean an activity involving the breaking of a free fall from an airplane using a parachute.

pre-notification / referral

In order to ensure your claims are addressed as efficiently as possible, you or the provider of service must contact the Assistance Company for Pre-notification prior to any medical treatment received in

the U.S., as well as hospital admissions and inpatient / outpatient surgeries incurred worldwide. The Assistance Company has trained personnel available twenty-four (24) hours a day, seven (7) days

a week throughout the year to answer your questions, provide assistance, and guide you to an appropriate facility. In the case of an Emergency Admission, the Assistance Company must be contacted within forty-eight (48) hours, or as soon as reasonably possible. Pre- notification does not guarantee that benefits will be paid.

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® Worldwide does not guarantee payment to a facility or individual for medical expenses until Seven Corners determines that it is an eligible expense.

refund of premium

8

Seven Corners realizes that there is uncertainty in worldwide travel. Refund of total plan cost will only be considered if written request is received by Seven Corners prior to the Effective Date of Coverage. If written request is received after the Effective Date of coverage, the unused portion of the plan cost may be refunded minus a cancellation fee, provided no claim has been submitted to Seven Corners for reimbursement.

claim submission

Filing a claim with Seven Corners is easy. You will receive a Liaison® Worldwide identification card and claim form after your application has been processed. When you receive treatment, send the original, itemized bills to Seven Corners within ninety (90) days. Eligible bills are automatically converted from local currencies to U.S. dollars. For payments of eligible medical expenses, notify Seven Corners of pending treatments and

we can refer you to approved healthcare providers worldwide. You’re only responsible for your deductible, coinsurance and non-eligible expenses. For more details, consult the Program Summary that is provided with your insurance kit, or contact the Seven Corners Claim Department.

description of exclusions

exclusions

For Medical benefits, this Insurance does not cover:

1.Any Injury or Illness that meets the following criteria: a) condition(s) that would have caused a person to seek medical advice, diagnosis, care or treatment during the thirty-six (36) months prior to the Effective Date of coverage under this Policy; b) condition(s) for which manifestation, medical advice, diagnosis, care or treatment was recommended, received, or noticed during the thirty-six (36) months prior to the Effective Date of coverage under this Policy.

If you are traveling outside the United States, the period is twelve (12) months instead of thirty-six (36) months.

If you are a United States citizen and the United States is your Home Country, this exclusion is waived for the first $20,000 in eligible medical expenses incurred outside the United States

(for persons age 65 and over, the amount is $2,500). This waiver does not include coverage for known, scheduled, required, or expected medical care, drugs, or treatments existent or necessary prior to the effective date of this program.

2. Charges for treatment which exceed Reasonable and Customary

9charges; or charges incurred for Surgeries or treatments which are Investigational, Experimental, or for research purposes; expenses which are non-medical in nature; expenses for Vocational, Speech, Recreational or Music Therapy.

3.Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician.

4.Suicide or any attempt there of, while sane, or self destruction or any attempt there of, while insane; intentionally self-inflicted Injury or Illness; or expenses as

a result of, or in connection with, the commission of a felony offense.

5.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.

6.Injury sustained while participating in professional, sponsored and/or organized Amateur or Interscholastic Athletics.

7.Routine physicals, inoculations, or other examinations where there are no objective indications or impairment in normal health.

8.Treatment of the Temporomandibular joint.

9.Services or supplies performed or provided by a Relative of yours, or anyone who lives with you.

exclusions (cont)

10.Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids, cosmetic or plastic Surgery

(including deviated nasal septum), routine dental expenses, eye care or eye-related expenses, unless caused by Accidental bodily Injury incurred while insured hereunder.

11.Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent; any Mental and Nervous disorders or rest cures; Injury sustained while under the

influence of or Disablement due wholly or partly to the effects of intoxicating liquor or drugs.

12.Congenital abnormalities and conditions arising out of or resulting therefrom.

13.Expenses incurred during a hospital emergency room visit that is not of an emergency nature.

14.Injury sustained while taking part in mountaineering, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle, snowmobiling, motorcycle / motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing and snow boarding. (Please see Optional Hazardous Sports Coverage to include some of these sports.)

• Mountaineering shall mean the sport, hobby or profession of

walking, hiking, and climbing up mountains either: 1) utilizing 10 harnesses, ropes, crampons or ice axes; or 2) ascending 4500 meters or above.

•Parachuting shall mean an activity involving the breaking of a free fall from an airplane using a parachute.

15.Treatment paid for or furnished under any other individual, government, or group policy or charges provided at no cost to you.

16.Treatment of venereal or sexually transmitted disease.

17.Pregnancy expenses or Illness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from an Accident.

18.Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth.

19.Expenses incurred while you are in your Home Country (except as provided under the Home Country Coverage benefit).

20.Expenses incurred for which travel was undertaken to seek medical treatment for a condition; or incurred after the Covered person’s physician has limited or restricted travel.

additional information

seven corners assist

Seven Corners Assist is a leading provider of customized emergency assistance services to worldwide organizations, corporations, government entities, insurance companies, and individual travelers. Regardless of the location, Seven Corners Assist provides valuable assistance in locating the best possible medical treatment.

the insurance company

Liaison® Worldwide is underwritten by Nationwide Mutual Insurance Company, Nationwide Life Insurance Company and Nationwide Mutual Fire Insurance Company.

the program administrator

Medical care is different throughout the world and providing quality medical attention should be the ultimate goal of any program. Most companies are not prepared to meet the unique needs of worldwide travelers. An organization must be equipped to address foreign currencies, worldwide doctors

11 and hospitals, as well as unusual claim forms and documents. Liaison® Worldwide is designed and administered by Seven

Corners, Inc. The claim and assistance professionals at Seven Corners collectively have over 250 years of experience in claim processing and administration.

wellabroad.com

In our ever changing world, Seven Corners’ WellAbroad® seeks to prepare individuals and groups with the advanced tools for successful travel. WellAbroad® offers medical, political and

cultural information and includes many benefits and educational resources, such as:

•Text messaging alerts - Registered users receive updates regarding weather emergencies, security issues, customs alerts, and health care or pandemic warnings.

•Provider network directory - Clients and travelers can create customized country profiles which allow instant access to

providers in the specified regions to which they are traveling.

•Online forums - Fellow travelers and Seven Corners’ staff post experiences and travel tips which can be accessed at any time.

Happy travels – www.wellabroad.com seven corners

Since 1993, Seven Corners, Inc. has alleviated many of the

12

concerns with worldwide travel by providing insurance plans to private citizens, governments, missionaries, students, and corporations of various nations around the globe. Each year,

thousands of insureds purchase coverage from Seven Corners in order to obtain the most comprehensive and reliable products in the international insurance industry.

Our assistance professionals are experienced in the complexity and importance of receiving medical care internationally. As an insured of Seven Corners, you can feel confident that there is someone ready to assist you with a medical situation 24 hours a day, 7 days a week, 365 days a year.

In California, operating under Seven Corners Insurance Services.

additional information

information

Liaison® Worldwide is available in all states for foreign nationals traveling in the United States. For a U.S. citizen traveling overseas, the program is available in selected states. For a current list of available states, please check with your agent or visit www.sevencorners.com for an up-to-date list.

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® Worldwide. In the event of any conflict between this brochure and the Master Policy, the Master Policy will govern. A Program Summary, listing more detailed exclusions, will be mailed to you along with Your ID Card once coverage is purchased.

Excluded Country List: Coverage is not available for travel to or from the following Countries*:

• Balkans Sanctions

13 • Belarus Sanctions

• Burma Sanctions

•Cote d’Ivoire (Ivory Coast)

•Cuba Sanctions

•Democratic Republic of Congo Sanctions

•Iran Sanctions

•Iraq Sanctions

•Liberia Sanctions

•North Korea Sanctions

•Palestinian Authority Sanctions

•Sudan Sanctions

•Syria Sanctions

•Zimbabwe Sanctions

*The above list is subject to change, please visit www.sevencorners.com for an up-to-date list.

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.

monthly & daily rates

Rates based on a $250 Deductible

Effective May 1, 2007

Traveling to the United States

If the applicant is traveling to, temporarily residing in, or visiting the United States, please use these rates.

Policy Maximum Options
Age	$50,000	$150,000	$300,000	$500,000
	Monthly / Daily	Monthly / Daily	Monthly / Daily	Monthly /
Daily	19 to 29	$46/$1.52	$56/$1.86	$61/$2.04
$72/$2.41
30 to 39	$61/$2.04	$75/$2.51	$83/$2.75	$96/$3.20
40 to 49	$92/$3.07	$108/$3.60	$118/$3.94	$141/$4.69
50 to 59	$141/$4.69	$180/$5.99	$197/$6.56	$205/$6.83
60 to 64	$171/$5.71	$226/$7.53	$247/$8.24	$266/$8.88
65 to 69	$219/$7.31	N/A	N/A	N/A
70 to 79	$276/$9.20	N/A	N/A	N/A
80 plus *	$480/$16.01	N/A	N/A	N/A
Each Dep. Child	$28/$0.93	$34/$1.12	$37/$1.23	$42/$1.40
Each Child Alone	$46/$1.53	$57/$1.89	$62/$2.07	$68/$2.27
Traveling Outside the U.S.
If the applicant is traveling outside the United States, please use these rates.
Policy Maximum Options
Age	$50,000	$150,000	$300,000	$500,000	14
	Monthly/Daily	Monthly/Daily	Monthly/Daily	Monthly/
Daily
19 to 29	$29/$0.96	$35/$1.15	$37/$1.23	$40/$1.33
30 to 39	$34/$1.14	$40/$1.33	$45/$1.50	$53/$1.77
40 to 49	$58/$1.93	$65/$2.17	$68/$2.27	$73/$2.43
50 to 59	$100/$3.33	$115/$3.84	$119/$3.95	$122/$4.07
60 to 64	$125/$4.18	$151/$5.04	$156/$5.19	$164/$5.46
65 to 69	$146/$4.88	$161/$5.37	$166/$5.53	$168/$5.61
70 to 79	$219/$7.30	$311/$10.37	$320/$10.68	N/A
80 plus*	$383/$12.77	N/A	N/A	N/A
Each Dep. Child	$20/$0.67	$25/$0.84	$26/$0.87	$27/$0.90
Each Child Alone	$32/$1.07	$36/$1.21	$37/$1.25	$40/$1.33

*Ages 80+ limited to $15,000. Dep. Child rate is applicable when at least one parent will also be covered under Liaison® Worldwide. Child Alone rate is used when a child will be insured by themselves.

Premium Example:

35-year-old U.S. citizen traveling to Spain, from March 15th to April 19th

$250 deductible and $50,000 maximum
March 15th through April 14th equals 1 month (calendar month)	$34.00
April 15th through April 19th equals 5 days $1.14 x 5	$ 5.70
Total Premium Submitted	$39.70

why liaison® worldwide

rapid processing

A “excellent ” rated, u.s. insurance company

professional customer service

24 hour worldwide assistance

online quote & purchase

about seven corners

Since 1993, Seven Corners has provided medical insurance to corporations, worldwide travelers, expatriates, students, overseas visitors, immigrants and global citizens. With expertise and efficiency, we’ve served clients in more than a hundred countries.

for additional information

visitorshield.com 4420 Pecos Ave Fremont, CA 94555

United States of America

P: 408-569-8190

enrolling in liaison® worldwide

1.Complete the entire Liaison® Worldwide Application. Payment for the entire period of coverage is due at the time of application.

2.If paying by check or money order, make payable to: “Seven Corners” and enclose it together with completed Application.

3.If paying by credit card, complete the Application and mail or fax to Seven Corners. Be sure to sign the Method of Payment section.

4.Read the brochure and sign the Application.

Return the Application with your payment for the total premium 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 if paying by credit card only. Originals are not required if application is faxed to Seven Corners with credit card payment.)

liaison® worldwide application

(please print or type using black ink)

Official Use Only:
Cert#:	Processed:	Eff. Date:

applicant information

Last Name:

First Name: M.I.:

Country of Permanent, fixed Residence:

(Home Country)

Passport Number/Country:

Departure Date from your Home Country? (MM/DD/YY) / / AD&D Beneficiary:

Relationship:

(Accidental Death & Dismemberment)

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 Seven Corners? qYes qNo ID #:

When would you like coverage to begin? (MM/DD/YY)

/ /

Destination?:

Length of trip?:

What is your expected return date? (MM/DD/YY) /

/

Please note: The minimum period of coverage is 5 days, the maximum is 12 months (please see Continuing Coverage Option). Coverage must be purchased in increments of no less than 5 days. Coverage cannot begin until your departure from your Home Country, nor will coverage begin before Seven Corners receives and accepts your application and correct payment.

coverage specifics

Are you traveling: qto the U.S. or qoutside the U.S.

Policy Maximum: q$50,000 q$150,000 q$300,000 q$500,000

Deductible:	Option	Factor
	q$0	1.30
	q$100	1.10
	q$250	1.00
	q$500	.90
	q$1000	.80
	q$2500	.70

continuing

Coverage Option: qNo qYes (must buy at least 3 months)

Coverage Option: qHazardous Sport Coverage (1.15)

In Florida, Florida Resident – Agent No. A269211

liaison® worldwide 2007

[pull-out application form]

effective may 1, 2007

Agent: 10781

calculating your plan cost

(Please complete entire section.)

Name of Person(s) to be Insured:

Date of Birth

Monthly

Daily

MM/DD/YY

Rate

Rate

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 of [A] and [B]:		$
Multiply by Deductible Factor:	x
	Total:	$
Multiply by Coverage Option Factor: (If applicable)	x
Total Payment Enclosed:		$

method of payment

qCheck	qMoney Order						qMasterCard
q Visa	qDiscover						qAmerican Express
Card Number:									CVV:
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 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 understand the terms and conditions of this product, as outlined in this brochure. I understand that Pre-existing 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 Nationwide Mutual Insurance Company, Nationwide Life Insurance Company and Nationwide Mutual Fire Insurance Company. May not be

available in all states.

Signature of Insured or Proxy (Required)

Date

(Proxy is someone acting on behalf of insured.)

liaison® worldwide 2007