Patriot America provides coverage for Non-US citizens traveling outside their country of citizenship for a
minimum of 5 days up to a maximum of two years. If the plan is purchased for a minimum of three months, coverage may be renewed
(without break in coverage) for a total of up to two years. See the "Extension of Coverage" section page 16 of the brochure for
more information.
If you or other family members applying for coverage are age 65 or older, please see the Eligibility section on page 16 of the
brochure for additional information.
Details on optional riders can be found on page 10, and more information on calculating your rates can be found on page
17 of the brochure.
|
PATRIOT AMERICA® MONTHLY POLICY
PREMIUMS (four Policy Maximum options)
|
|
50,000 MAX |
100,000 MAX |
500,000 MAX |
1,000,000
MAX |
|
option 1 |
option 2 |
option 3 |
option 4 |
|
AGE
|
One Month |
One Month |
One Month |
One Month |
|
18-29
|
$43.00
|
$50.00
|
$64.00
|
$76.00
|
|
30-39
|
$56.00
|
$67.00
|
$84.00
|
$97.00
|
|
40-49
|
$84.00
|
$96.00
|
$126.00
|
$142.00
|
|
50-59
|
$120.00
|
$147.00
|
$178.00
|
$206.00
|
|
60-64
|
$142.00
|
$174.00
|
$207.00
|
$248.00
|
|
65-69
|
$162.00
|
$208.00
|
$226.00
|
$270.00
|
|
70-79
|
$219.00
|
N/A
|
N/A
|
N/A
|
|
80+*
|
$381.00
|
N/A
|
N/A
|
N/A
|
|
DEP CHILD
|
$26.00
|
$28.00
|
$36.00
|
$39.00
|
|
CHILD ALONE
|
$39.00
|
$46.00
|
$59.00
|
$66.00
|
| *US$10,000 limit |
|
|
PATRIOT AMERICA® DAILY RATES (MINIMUM
COVERAGE IS 5 DAYS)
|
|
50,000 MAX |
100,000 MAX |
500,000 MAX |
1,000,000
MAX |
|
option 1 |
option 2 |
option 3 |
option 4 |
|
AGE
|
Daily |
Daily |
Daily |
Daily |
|
18-29
|
$1.45
|
$1.75
|
$2.20
|
$2.55
|
|
30-39
|
$1.90
|
$2.25
|
$2.85
|
$3.25
|
|
40-49
|
$2.85
|
$3.25
|
$4.25
|
$4.80
|
|
50-59
|
$4.05
|
$4.95
|
$6.00
|
$6.90
|
|
60-64
|
$4.80
|
$5.85
|
$6.95
|
$8.35
|
|
65-69
|
$5.45
|
$7.00
|
$7.60
|
$9.05
|
|
70-79
|
$7.35
|
N/A
|
N/A
|
N/A
|
|
80+*
|
$12.75
|
N/A
|
N/A
|
N/A
|
|
DEP CHILD
|
$.90
|
$1.00
|
$1.25
|
$1.35
|
|
CHILD ALONE
|
$1.35
|
$1.60
|
$2.00
|
$2.25
|
| *US$10,000 limit |
|
|
All premium rates are in US dollars and are effective through 10/31/2008. Rates include 2.5% surplus lines tax. A
dependent child is your child shown on the Enrollment Form over 14 days and under 18 years of age, traveling with you, and for whom
premium has been paid.
*See specific policy for age limit.
Benefit Period
If a covered injury or illness requires continuing treatment after the policy expires, the Benefit Period may provide continued
coverage. When the policy expires, IMG will review the date of the initial treatment for the covered injury or illness. If
treatment began less than six months before the policy expired, benefits for the covered injury or illness will continue subject to
the Policy Limits until there has been six months of coverage. The Benefit Period serves as an extension of benefits and does not
limit the treatment time during the Policy Period.
Refund of Premium
Your satisfaction is very important to the plan underwriter, and to IMG as the plan administrator. If, for any reason, you are not pleased
with this product, you may submit a written request for cancellation and refund of your premium. In order to be considered for a full refund,
your request for cancellation must be received by IMG prior to your effective date. If you do not have any claims filed with IMG, you may
cancel your plan after your effective date, however, the following conditions will apply: 1)you will be required to pay a US$25 cancellation
fee and 2)only full month premiums will be considered for refunds (e.g., if you choose to cancel your coverage for two months and two weeks
prior to the date your coverage ends, IMG will only consider the two full months for a refund). If you have filed claims, your premium is
non-refundable.
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.
2960 North Meridian Street
Indianapolis, IN 46208 U.S.A.
Please include Identification Number in all correspondence.
This is only a consolidated and summary description of all current Patriot Travel Medical Insurance benefits,
conditions, limitations and exclusions. A certificate containing the complete Policy Wording with all terms, conditions and
exclusions will be included with the fulfillment kit. In support of Patriot Travel Medical Insurance SM,
IMG has established the Global Medical Services Group Insurance Trust in Indiana. The trust owns a master group international
travelers insurance policy. Individual certificates of insurance are issued from the master policy.
Underwritten by: Sirius International Insurance Corporation
