why choose seven corners?

why you need this program

The United States offers the most comprehensive medical care, but it is often complicated as well as very expensive. For a visitor to the United States, finding an insurance program that is easy to understand and reasonably priced is often difficult.

As a solution, Inbound® Guest was developed to provide a simple and affordable program to visitors.

This is a brief description of the Inbound® Guest program. Detailed wording is outlined in the Program Summary, which will be e-mailed to you once you have enrolled in Inbound® Guest.

eligibility

This program is available to non-United States citizens who come to the U.S. for business, pleasure, or to study. The program must become effective within 180 days of arrival in the United States.

network

What does this mean for you? If you visit one of our network physicians or facilities, the bill from your provider will

1 automatically be reviewed for possible discounts. The scheduled benefit limits and the deductible will then be applied. If there is a remaining balance, you will be notified of the amount you owe. Please note: the amount of the discount varies based on the doctor, hospital and procedure. In some cases, a reduction in pricing may not be available.

You are not required to use our network; however any treatment received outside of the network will not be presented for possible discounts.

description of coverage

period of coverage

You may initially enroll in Inbound® Guest for as little as 5 days and up to maximum of 180 days. Total period of coverage for Inbound® Guest cannot exceed 180 days (in order to reapply after the 180 days, you must first return to your home country).

effective date - Your coverage will begin at 12:01 AM North American Eastern Time on the latest of the following:

1.Your departure from your Home Country; or

2.The date your Application and premium are received by Seven Corners; or

3.The date your Application and premium are accepted by Seven Corners; or

4.The date you request on the Application.

expiration date - Your coverage will end at 12:01 AM North American Eastern Time on the earlier of the following:

1. The date shown on the Insurance Confirmation Card, for which premium has been paid; or

2. The date you return to your Home Country; or 3. 180 days after your original Effective Date; or 4. The day an insured becomes a U.S. citizen; or

5. The date of entry into active military service.

2

home country

Home country is defind as the country where an Insured Person has his or her true, fixed and permanent residence.

Upon each renewal, the rates, benefits, and program in general are subject to change.

schedule of benefits

If your covered Injury or Sickness requires treatment by a physician, this program will provide benefits up to the scheduled amount, as listed in the Schedule of Benefits, which exceed

the chosen Per Person Deductible($0, $50 or $100, or a $200 deductible for age 70 and over) for each Injury and each Sickness and which are incurred within the 26 weeks following the Injury or Sickness. Payment for any covered service will not exceed the Benefit Maximum shown. The maximum amount payable for all benefits will be no more than $25,000, $45,000, $65,000, $85,000 or $120,000 for each Injury and each Sickness.

For persons age 70 and over, the maximum benefit limit is $40,000, $60,000 or $100,000 for each Injury or Sickness. The period in which covered expenses must be incurred is 26 weeks following the Injury or Sickness, and a separate schedule applies.

description of coverage

international travel coverage

An Insured Person may travel to additional countries, other than the United States, up to a maximum of thirty (30) days. You must purchase a minimum of one (1) month of coverage. International travel coverage does not include travel back to the Insured Person’s home country, and it does not extend after your current expiration date. International travel must be utilized during your current Period of Coverage.

emergency medical evacuation expenses

The program will pay up to $50,000 in Covered Expenses incurred if any covered Injury or Sickness originating 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 Person’s local attending Physician. *

repatriation of mortal remains expenses

7 The program will pay the reasonable Covered Expenses incurred, up to a maximum of $7,500, to return the Insured Person’s

remains to his/her Home Country if he or she dies.*

common carrier accidental death & dismemberment (ad&d)

Accidental Death and Dismemberment shall apply to covered accidents sustained by an insured person while riding as a passenger in or on any land, water or air conveyance operated under a license for the transportation of passengers for hire. A loss must occur within 365 days after the date of accident causing the loss:

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

exclusions and limitations

exclusions

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

1.Pre-existing Conditions;

2.Any expenses incurred when travel was undertaken solely for the purpose of obtaining medical treatment or while traveling against the advice of a Physician;

3.Expense incurred within the Insured Person’s Home Country or country of regular domicile;

4.Routine physicals, inoculations, or other examinations where there are no objective indications of impairment of normal health, or well baby care, new-born baby care; well-baby nursery and related Physician charges;

5.Prescriptions or fitting of eyeglasses and contact lenses; eye examinations; or other treatment for visual defects and problems.

“Visual defects” means any physical defect of the eye which does or can impair normal vision;

6.Hearing examinations or hearing aids; or other treatment for hearing defects and problems. “Hearing defects” means any physical defect of the ear which does or can impair normal hearing:

7.Dental treatment, except as the result of injury to sound, natural teeth;

8.Services or supplies performed or provided by a Member of the Insured Person’s family, or anyone who lives with the Insured Person;

9. Expenses which were not recommended, approved and certified	8
as Medically Necessary and reasonable by a Physician;

10.Weak, strained or flat feet, corns, calluses, or toenails;

11.Cosmetic surgery, or treatment for congenital anomalies (except as specifically provided), except reconstructive surgery as the result of a covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or covered Sickness;

12.Elective Surgery and Elective Treatment;

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

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

15.Organ transplants;

16.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);

17.Participation in a riot or civil disorder, commission of or attempt to commit a felony in the country in which it was attempted or committed;

18.Suicide or attempted suicide (including drug overdose), while sane or insane (while sane in Missouri), or an intentionally self-inflicted Injury;

19.Expenses of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;

exclusions and limitations

exclusions (cont.)

20.Treatment of nervous or mental disorders, except as stated in the Schedule of Benefits, or treatment of alcoholism or drug abuse, except as provided for treatment of mental or nervous disorders, according to the Schedule of Benefits;

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

22.Treatment services, supplies or facilities in a hospital owned or operated by: a) The Veteran’s Administration; or b) A national government or any of its agencies. (This exclusion does not apply to treatment when a charge is made which the Insured is required by law to pay);

23.Duplicate services actually provided by both a certified nurse- midwife and Physician;

24.Expenses incurred during a hospital emergency room visit which is not of an emergency nature;

25.Expenses incurred for outpatient treatment in connection with 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 and the

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

26.Injury sustained 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, 9 motorcycle/motor scooter riding, scuba diving involving

underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing, snow boarding and snowmobiling;

27.Treatment paid for or furnished under any other individual, government, or group policy; previous policy; payable under any Worker’s Compensation or Occupational Disease Law or Act; or charges provided at no cost to the Insured Person;

28.Expense incurred after the Expiration Date for an Insured Person except as may be specifically provided;

29.Expenses for treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent or for Injury or Sickness due wholly or partly to the effects of intoxicating liquor or drugs, unless prescribed by a Physician;

30.Sexually transmitted diseases, including AIDS;

31.Pregnancy expenses or Sickness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from Injury; or voluntary or elective abortion;

32.Treatment while confined primarily to receive custodial care, educational or rehabilitative care and nursing services in a long term facility, spa, hydroclinic, weight loss clinic, sanatorium, nursing home or similar facilities;

33.Expenses for Speech therapy, Occupational therapy or Vocational Rehabilitation.

definitions

definitions

injury shall mean bodily Injury listed in the most recent edition of the International Classification of Diseases and caused solely and directly by Accidental, external, and visible means occurring while this Certificate is in force and resulting directly and independently of all other causes resulting in a Covered Event under this Program.

sickness shall mean Illness or Disease of any kind listed in the most recent edition of the International Classification of Diseases. All related conditions and recurrent symptoms of the same or a similar condition will be considered one Sickness.

pre-existing condition shall mean 1) A condition that would have caused a person to seek medical advice, diagnosis, care or Treatment within the 6 months (or 12 months for persons ages 70 and older) prior to the Individual Effective Date of Coverage under this program; 2) A condition for which medical advice, diagnosis, care or Treatment, including Medication, was sought, recommended or received within the 6 months (or 12 months for persons ages 70 and older) prior to the Individual Effective Date of Coverage under this program; 3) The symptoms which occurred within the 6 months (or 12 months for persons ages 70 and older)

prior to the Individual Effective Date of the Coverage under this 10 Certificate would have allowed a person trained in medicine to make a diagnosis of the condition producing the symptoms;

4) A condition which manifested itself within the 6 months (or 12 months for persons ages 70 and older) prior to the Individual Effective Date of Coverage under this Certificate;

additional information

Please be aware that this is not a general health insurance policy, but an interim program intended for temporary use. Inbound® Guest does not guarantee payment to a facility or individual for medical expenses until the Company determines that it is an eligible expense.

renewal

You will have the option to renew in whatever increment you choose (Minimum 5 day purchase). There is a $5 administration fee each time you renew. Again, the total period of coverage for Inbound® Guest cannot exceed 180 days.

refund of premium

Seven Corners realizes that there is uncertainty in international 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.

the insurance company

11

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

seven corners

Since 1993, Seven Corners 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.

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

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 Surplus Lines Taxes and fees will apply. If so, Seven Corners will request the payment of the additional Surplus Lines Taxes and fees from you prior to issuing coverage. The additional Surplus Lines Taxes and fees shall be listed on the declaration page of your policy.

plan cost

	Daily Rates Effective February 1, 2012
	$0 Per Injury / Sickness Deductible Per Person
	Policy Maximum Options
		Plan A	Plan B	Plan C	Plan D	Plan E
		$25,000	$45,000	$65,000	$85,000	$120,000
	Age	Daily Rate	Daily Rate	Daily Rate	Daily Rate	Daily Rate
	2 weeks -18	$0.98	$1.36	$1.67	$1.88	$2.44
	19 to 29	$0.81	$1.13	$1.38	$1.55	$2.02
	30 to 39	$0.91	$1.26	$1.55	$1.75	$2.27
	40 to 49	$0.98	$1.36	$1.67	$1.88	$2.44
	50 – 59	$1.34	$1.85	$2.25	$2.52	$3.27
	60 - 69	$1.49	$2.06	$2.51	$2.81	$3.64
	Dependent Child*	$0.93	$1.29	$1.59	$1.79	$2.32
	$50 Per Injury / Sickness Deductible Per Person
	Policy Maximum Options
		Plan A	Plan B	Plan C	Plan D	Plan E
		$25,000	$45,000	$65,000	$85,000	$120,000
	Age	Daily Rate	Daily Rate	Daily Rate	Daily Rate	Daily Rate
	2 weeks - 18	$0.82	$1.13	$1.39	$1.56	$2.03
	19 to 29	$0.68	$0.94	$1.15	$1.29	$1.67
	30 to 39	$0.76	$1.05	$1.29	$1.45	$1.88
	40 to 49	$0.82	$1.13	$1.39	$1.56	$2.03
	50 –59	$1.12	$1.55	$1.89	$2.11	$2.74
	60 – 69	$1.24	$1.72	$2.10	$2.34	$3.04
	Dependent Child*	$0.78	$1.07	$1.32	$1.48	$1.93
	$100 Per Injury / Sickness Deductible Per Person
	Policy Maximum Options
		Plan A	Plan B	Plan C	Plan D	Plan E
		$25,000	$45,000	$65,000	$85,000	$120,000	12
	Age	Daily Rate	Daily Rate	Daily Rate	Daily Rate	Daily Rate
	2 weeks – 18	$0.76	$1.05	$1.29	$1.45	$1.89
	19 to 29	$0.62	$0.86	$1.06	$1.20	$1.56
	30 to 39	$0.70	$0.97	$1.19	$1.35	$1.75
	40 to 49	$0.76	$1.05	$1.29	$1.45	$1.89
	50 – 59	$1.03	$1.43	$1.78	$2.03	$2.67
	60 – 69	$1.16	$1.60	$1.98	$2.26	$2.96
	Dependent Child*	$0.72	$1.00	$1.23	$1.38	$1.80

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

Monthly/ Daily Premiums for Ages 70 and Older

$100 Per Injury / Sickness Deductible Per Person Policy Maximum Options

	Plan J	Plan K	Plan L
Age	$40,000	$60,000	$100,000
	Daily Rate	Daily Rate	Daily Rate
Age 70 – 74	$2.47	$3.58	$5.81
Age 75 – 79	$2.72	$3.94	$6.40
Age 80 – 84	$5.48	$7.92	$12.87
Age 85 – 89	$7.90	$11.42	$18.56
Age 90 – 94	$8.55	$12.36	$20.09
Age 95 – 99	$9.83	$14.21	$23.09
$200 Per Injury / Sickness Deductible Per Person
Policy Maximum Options
	Plan J	Plan K	Plan L
Age	$40,000	$60,000	$100,000
	Daily Rate	Daily Rate	Daily Rate
Age 70 – 74	$2.06	$2.98	$4.84
Age 75 – 79	$2.27	$3.28	$5.32
Age 80 – 84	$4.57	$6.61	$10.74
Age 85 – 89	$6.73	$9.73	$15.81
Age 90 – 94	$7.29	$10.54	$17.12
Age 95 – 99	$8.37	$12.10	$19.66

why inbound® guest

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 EMAIL: visitorshield@gmail.com

P: 408-569-8190

Visitor Shield

enrolling in inbound® guest

1.Complete and sign entire application

2.Select method of payment.

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

4.If paying by credit card, complete Application and mail or fax to Seven Corners. Be sure to sign both sections, includ- ing the Method of Payment section.

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

inbound® guest 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:

for accidental death & dismemberment benefit

Beneficiary: Relationship:

us address of correspondence (address must be in the united states)

Name:

Address:

City:

State:

Postal Code:

Country:

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 six (6) months of your arrival in the United States. The minimum period of coverage is 5 days, maximum is one hundred and eighty (180) 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: qPlan A: $25,000

qPlan B: $45,000

qPlan C: $65,000

qPlan D: $85,000

qPlan E: $120000

Age 70 to 99:

qPlan J: $40,000

qPlan K: $60,000

qPlan L: $100,000

Selected Per Injury/Sickness Deductible:

q$0

q$50

q$100

q$200

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

[pull-out application form]

effective February 1, 2012

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 15 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:

CVV:

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 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 insurance product, but a limited benefit program designed to provide basic benefits under certain

circumstances. I also understand that Lloyds 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).

.

Signature of Insured or Proxy (Required)

Date