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PATRIOT
TRAVEL MEDICAL INSURANCEsm Coverage for non-US citizens traveling outside their country of citizenship from 15 days to one year. If you or other family members applying for coverage are age 65 or older, please see the Eligibility section for additional information. If you are traveling for six months or more, review the ExPatriot Plussm plan for additional coverage options. Once the Period of Coverage expires, Patriot Americasm can be rewritten but is not renewable. This means new Deductible, Coinsurance, Eligibility, Conditions of Coverage and Pre-Existing Condition Exclusions apply to any subsequent Period of Insurance. Policy Premiums |
PATRIOT AMERICA |
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| 50,000 MAX | 250,000 MAX | 500,000 MAX | ||||
AGE |
One Month | 15 Days | One Month | 15 Days | One Month | 15 Days |
18-29 |
$59.00 | $45.00 | $79.00 | $53.00 | $90.00 | $60.00 |
30-39 |
$76.00 | $57.00 | $101.00 | $68.00 | $115.00 | $80.00 |
40-49 |
$112.00 | $84.00 | $150.00 | $100.00 | $170.00 | $115.00 |
50-59 |
$149.00 | $111.00 | $198.00 | $133.00 | $225.00 | $150.00 |
60-64 |
$185.00 | $139.00 | $246.00 | $165.00 | $280.00 | $180.00 |
65-69 |
$211.00 | $158.00 | $282.00 | $189.00 | $320.00 | $210.00 |
70-79 * |
$235.00 | $176.00 | N/A | N/A | N/A | N/A |
80 PLUS** |
$420.00 | $315.00 | N/A | N/A | N/A | N/A |
DEP CHILD |
$35.00 | $30.00 | $40.00 | $27.00 | $45.00 | $35.00 |
CHILD ALONE |
$71.00 | $53.00 | $70.00 | $47.00 | $80.00 | $55.00 |
*50,000 limit |
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**10,000 limit |
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*A dependent child is your child shown on the Enrollment Form under 18 years of age, traveling with you and for whom premium has been paid.
Premiums effective through 12/31/99.
*See specific policy for age limit.
Benefit Period The Benefit Period is the period of time specified in the Policy Limits. It begins once an eligible incident occurs to the insured. While coverage is in effect under this policy, the Benefit Period does not apply. When coverage under this policy terminates, as defined, Patriot Travel Medical Insurance sm will pay eligible expenses for covered Injuries or Illnesses which commenced during the period of coverage for up to, but not exceeding the Benefit Period, subject to the Policy Limits.
Refund of Premium............................
IMG will refund premium only if a written request is received prior to the policy's effective date. The premium is non-refundable after that date.
For Precertification, Emergency Evacuation and Repatriation..............
Please call IMG
in the U.S. 1.800.628.4664
Outside the U.S. 01.317.655.4500
(collect if necessary).
IMG must be notified prior to treatment or within 48 hours of an emergency.
To Report
Claims...............................
Please mail to IMG
International Medical Group, Inc.
407 North Fulton Street
Indianapolis, IN 46202 U.S.A.
Please include Identification Number in all correspondence.
This brochure is only a summary of coverage provided. Other conditions and exclusions may apply. Please consult the policy itself for a full description of the coverage. In support of Patriot Travel Medical Insurance sm, IMG has established the Group Health, Accident and Travel Insurance Trust, in Washington D.C. The trust owns a master group international travelers insurance policy. Individual certificates of insurance are issued from the master policy. Rates include 2% surplus lines tax.
Underwritten by: Sirius International Insurance Corporation
| Patriot Home | Protection Package | Claim
Management |
| Plan Administrator | Underwriter | Enrollment
| Enrollment Form |
| Conditions and Exclusions |
